Nursing Elites

1. What does the 'B' in the SBAR acronym stand for?

• A. Background
• B. Basic
• C. Beginning
• D. Break

Correct answer: A

Rationale: The 'B' in the SBAR acronym stands for Background. SBAR is a standardized communication tool used in healthcare to effectively communicate critical information. In this context, 'Background' refers to providing relevant information about the patient's history, current status, and any other pertinent details. This information helps ensure clear and concise communication between healthcare providers, enhancing patient care. Choice B, 'Basic,' is incorrect as the 'B' specifically emphasizes the detailed background information. Choices C and D, 'Beginning' and 'Break,' are not accurate in the context of the SBAR communication tool.

2. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.

3. Which of the following is a true statement about assessing blood pressure by palpation?

• A. Only the diastolic blood pressure can be assessed through palpation.
• B. The palpation technique is most useful for infants and small children.
• C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
• D. Only the systolic blood pressure can be assessed through palpation.

Correct answer: D

Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.

4. Which of these devices is considered a protective device, rather than a restraint?

• A. A mitten on the hands to prevent scratching
• B. A mitten on the hands to prevent the person from pulling their IV out
• C. A side rail to prevent the patient from falling
• D. A soft wrist restraint to prevent the patient from pulling their IV tubing

Correct answer: A

Rationale: A mitten on the hands to prevent scratching is considered a protective device because its primary purpose is to protect the patient from harming themselves by scratching. It does not restrict the patient's movement. Choice B, a mitten on the hands to prevent the person from pulling their IV out, is considered a restraint as it limits the patient's movement. Choice C, a side rail to prevent the patient from falling, is also a protective device as it aims to keep the patient safe by providing support and preventing falls. Choice D, a soft wrist restraint to prevent the patient from pulling their IV tubing, is a type of restraint as it restricts the patient's movement to prevent them from interfering with medical equipment.

5. Mrs. G is seen for follow-up after testing for chronically high blood glucose levels. Her physician diagnoses her with type 1 diabetes. Which of the following information is part of this client's education about this condition?

• A. Type 1 diabetes occurs due to increased carbohydrate intake and lack of exercise
• B. Type 1 diabetes is managed through diet and exercise
• C. Type 1 diabetes is caused by destruction of beta cells in the pancreas
• D. Type 1 diabetes leads to the body's cells rejecting insulin

Correct answer: C

Rationale: Type 1 diabetes is an autoimmune condition where the immune system attacks and destroys the beta cells in the pancreas, leading to a lack of insulin production. Insulin is essential for regulating blood glucose levels and enabling cells to use glucose for energy. Understanding that type 1 diabetes results from the destruction of beta cells helps patients comprehend the need for insulin replacement therapy. Choices A and B are incorrect as type 1 diabetes is not primarily caused by diet or exercise habits. Choice D is incorrect because type 1 diabetes is not about the body's cells rejecting insulin but rather the lack of insulin production due to beta cell destruction.

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