Nursing Elites

1. What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?

• A. The popliteal artery should be auscultated to obtain thigh pressure.
• B. The best position to measure thigh pressure is the prone position.
• C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
• D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.

Correct answer: C

Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.

2. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)

• A. Eliminate the reservoir
• B. Block the portal of exit from the reservoir
• C. Block the portal of entry into the host
• D. Decrease the susceptibility of the host

Correct answer: B

Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.

3. When considering the structural organization of the human body, what is the basic unit of life?

• A. Chemicals
• B. Atoms
• C. Molecules
• D. Cells

Correct answer: D

Rationale: The basic unit of life is the cell. Cells are considered the fundamental unit of life because they are capable of carrying out all the processes necessary for life, such as growth, reproduction, responding to stimuli, and more. While chemicals, atoms, and molecules are essential components of cells and living organisms, they are not considered the basic unit of life. Chemicals are general substances, atoms are the smallest units of matter, and molecules are combinations of atoms. Therefore, the correct answer is cells, as they are the building blocks of all living organisms.

4. A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:

• A. The reason for administering the wrong dose
• B. The type of drug involved
• C. The amount of insulin that was given
• D. Any adverse effects on the client

Correct answer: A

Rationale: When completing an incident report for a medication error, it is essential to include factual information such as the type of drug involved, the amount administered, and any adverse effects on the client. However, stating the reason for administering the wrong dose should be avoided in documentation. The focus should be on reporting what happened rather than assigning blame or admitting fault. This approach helps in ensuring a thorough and accurate account of the medication error without introducing subjective elements that could complicate the investigation or resolution process. Therefore, the correct answer is 'The reason for administering the wrong dose.' Choices A, B, and D are vital components of incident report documentation, providing crucial details that help in understanding the error and its impact on the client.

5. A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?

• A. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise.
• B. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus dysrhythmia.
• C. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds.
• D. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.

Correct answer: B

Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic blood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds. An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.

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