Nursing Elites

1. What is the flap of tissue that covers the trachea upon swallowing called?

• A. Epidermis
• B. Endocardium
• C. Epiglottis
• D. Epistaxis

Correct answer: C

Rationale: The correct answer is C: Epiglottis. The epiglottis is a flap of tissue that covers the trachea when swallowing to prevent food or liquid from entering the airway. Choice A, Epidermis, is the outer layer of the skin and is not related to the trachea. Choice B, Endocardium, is the inner lining of the heart chambers and is also unrelated to the trachea. Choice D, Epistaxis, refers to a nosebleed and is not the correct term for the tissue covering the trachea.

2. What does preload refer to?

• A. The volume of blood entering the left side of the heart
• B. The volume of blood entering the right side of the heart
• C. The pressure in the venous system that the heart must overcome to pump the blood
• D. The pressure in the arterial system that the heart must overcome to pump the blood

Correct answer: B

Rationale: Preload refers to the volume of blood that enters the right side of the heart. This volume stretches the fibers in the heart before contraction. Preload is an essential factor in determining the force of ventricular contraction. Choices A, C, and D are incorrect. Choice A is incorrect because preload is specifically related to the volume of blood entering the right side of the heart. Choices C and D are incorrect as they refer to afterload, which is the pressure that the heart must overcome to pump blood out of the ventricles into the systemic or pulmonary circulation.

3. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

• A. A little, a moderate amount, or all of the meal
• B. 50 cc, 100 cc, or 500 cc of the meal
• C. 25%, 50%, or 100% of the meal
• D. Either A or C

Correct answer: C

Rationale: Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.

4. When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?

• A. Respirations are measured first, followed by pulse and temperature.
• B. Vital signs should be measured as frequently as in an adult.
• C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
• D. The nurse should first measure the infant's vital signs before performing a physical examination.

Correct answer: A

Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.

5. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

• A. These readings are a normal response and attributable to changes in the patient's position.
• B. The change in blood pressure readings is called orthostatic hypotension.
• C. The blood pressure reading in the lying position is within normal limits.
• D. The change in blood pressure readings is considered within normal limits for the patient's age.

Correct answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of �20 mm Hg or �10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.

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