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. When considering the concepts related to blood pressure, which statement best describes the concept of mean arterial pressure (MAP)?

• A. MAP is the pressure of the arterial pulse.
• B. MAP reflects the stroke volume of the heart.
• C. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
• D. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.

Correct answer: C

Rationale: Mean Arterial Pressure (MAP) is the pressure that forces blood into the tissues, averaged over the cardiac cycle. It is not the pressure of the arterial pulse (Choice A), nor does it directly reflect the stroke volume of the heart (Choice B). While MAP involves systolic and diastolic pressures, it is not simply an average of these two values as diastole lasts longer. Instead, MAP is closer to diastolic pressure plus one third of the pulse pressure. The best description of MAP is that it represents the pressure forcing blood into the tissues, averaged over the cardiac cycle.

3. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to:

• A. Give the client orientation materials and review the unit rules and regulations.
• B. Introduce him/her and accompany the client to the client's room.
• C. Take the client to the day room and introduce him/her to the other clients.
• D. Ask the nursing assistant to get the client's vital signs and complete the admission search.

Correct answer: B

Rationale: Anxiety is triggered by change that threatens the individual's sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. The correct initial response is to introduce the client and accompany them to their room. This approach helps the client feel oriented, safe, and supported. Giving orientation materials or reviewing rules and regulations may overwhelm the client further. Taking the client to the day room and introducing them to other clients could increase anxiety by exposing them to unfamiliar faces. Asking the nursing assistant to get vital signs and complete admission tasks can wait until the client feels more settled and secure in their environment.

4. The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should:

• A. Formulate post-discharge nursing diagnoses
• B. Draw conclusion about resolution of current client problems
• C. Assess the client for baseline data to be used at the LTC facility
• D. Plan the care that is needed in the LTC facility

Correct answer: B

Rationale: To effectively communicate the client's outcome goals that were met and those that were not to the LTC staff, the nurse should draw conclusions about the resolution of the current client problems. Terminal evaluation is performed to determine the client's condition at discharge, focusing on which goals were achieved and which were not. Formulating post-discharge nursing diagnoses (option A) is not the most appropriate action in this scenario as it focuses on identifying potential problems after discharge rather than evaluating achieved goals. Assessing the client for baseline data (option C) is not necessary at this point as the focus is on evaluating outcomes rather than collecting baseline data. Planning the care needed in the LTC facility (option D) is premature as this should be done on admission to the LTC facility and not during the discharge process.

5. A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?

• A. Do not perform the procedure. Notify the physician of the reason why.
• B. Perform the procedure but pay close attention for signs of potential syncope.
• C. Allow the patient to reschedule for a time when he isn't as anxious.
• D. Have the physician draw the blood.

Correct answer: B

Rationale: In the scenario where a patient is sweating and anxious, it is important to assess for signs of potential syncope (fainting) while proceeding with the blood draw. If the patient does not exhibit signs of fainting, the phlebotomy procedure can be performed safely. Postponing the procedure may not address the patient's anxiety and inconvenience them. Having the physician draw the blood is not necessary if the phlebotomist can handle the situation effectively.

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