Nursing Elites

1. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

• A. Collect the blood sample
• B. Assess radial pulse volume
• C. Apply pressure to the site
• D. Select another finger

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

2. The nurse is teaching a client about coronary artery disease (CAD) preventive health. Which behavior stated by the client indicates a need for additional information and teaching?

• A. Increasing physical activity.
• B. Eating a low-fat diet.
• C. Decreasing the number of cigarettes smoked per day.
• D. Monitoring blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Decreasing the number of cigarettes smoked per day is not sufficient for CAD prevention. Smoking cessation is crucial in reducing the risk of CAD. While increasing physical activity, eating a low-fat diet, and monitoring blood pressure regularly are all positive behaviors for CAD prevention, quitting smoking should be emphasized due to its significant impact on cardiovascular health.

3. A client with chronic obstructive pulmonary disease (COPD) presented with shortness of breath. Oxygen therapy was started at 2 liters/minute via nasal cannula. The arterial blood gases (ABGs) after treatment were pH 7.36, PaO2 52, PaCO2 59, HCO3 33. Which statement describes the most likely cause of the simultaneous increase in both PaO2 and PaCO2?

• A. The client is hyperventilating due to anxiety.
• B. The hypoxic drive was reduced by the oxygen therapy.
• C. The client is experiencing respiratory alkalosis.
• D. The client is experiencing metabolic acidosis.

Correct answer: B

Rationale: Oxygen therapy can reduce the hypoxic drive in COPD patients, leading to increased PaCO2 levels while improving oxygenation (PaO2). In this case, the increase in PaO2 and PaCO2 is due to the reduction of the hypoxic drive by the supplemental oxygen. Choice A is incorrect because hyperventilation would lead to decreased PaCO2. Choice C is incorrect as the ABG values do not indicate respiratory alkalosis. Choice D is incorrect as the ABG values do not support metabolic acidosis.

4. What is the most common method of attempted suicide?

• A. Hanging
• B. Drug overdose
• C. Gunshot
• D. Slashing the wrists

Correct answer: B

Rationale: Drug overdose is the most common method of attempted suicide. While hanging, gunshot, and slashing the wrists are also methods used in suicide attempts, statistics show that drug overdose is the most prevalent method chosen by individuals attempting suicide. Hanging, gunshot, and slashing the wrists are indeed common methods as well, but drug overdose ranks highest in terms of frequency.

5. When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?

• A. Limited eye movement.
• B. Decreased peripheral vision.
• C. Blurred distance vision.
• D. Photosensitivity.

Correct answer: B

Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.

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