Nursing Elites

1. Patients exhibiting signs of cyanosis will:

• A. show signs of hyperoxia.
• B. have increased O2 saturation.
• C. have blood levels of CO2 higher than O2 levels.
• D. None of the above.

Correct answer: C

Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.

2. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

3. When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?

• A. Goggles
• B. Gown
• C. Surgical mask
• D. Clean gloves

Correct answer: A

Rationale: Goggles may be reused unless they are overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off. Gowns are at high risk for contamination and should be used only once and then discarded or washed. Surgical masks and gloves should never be washed or reused. Goggles provide eye protection from splashes and should be cleaned and disinfected after each use to ensure proper protection.

4. The most accurate reading for a temperature is done:

• A. Orally
• B. Aurally through a clean canal
• C. Rectally
• D. Axially

Correct answer: B

Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.

5. The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?

• A. Onset of labor in a pregnant woman
• B. Stroke
• C. Heart attack
• D. Migraine

Correct answer: B

Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care. Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.

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