Nursing Elites

1. The client with multiple sclerosis is being educated by the nurse on exercises and physical activities. Which statement by the client indicates a need for further teaching?

• A. "I can lift weights and engage in resistance training."?
• B. "I should exercise until I am exhausted."?
• C. "I can incorporate aerobic exercises into my routine."?
• D. "I should perform proper stretching before starting my routine."?

Correct answer: B

Rationale: The correct answer is, "I should exercise until I am exhausted."? This statement indicates a need for further teaching because patients with multiple sclerosis should avoid exercising to the point of exhaustion or fatigue. Strenuous physical activity can increase body temperature and potentially worsen symptoms in individuals with multiple sclerosis. Choice A is correct because lifting weights and resistance training can be appropriate exercises for patients with multiple sclerosis. Choice C is valid because aerobic exercises can also be beneficial. Choice D is accurate as proper stretching before starting an exercise routine is essential for preventing injuries.

2. A nurse is assessing a client's pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client's bed. Which of the following best describes the rationale for this intervention?

• A. External light sources may cause falsely high oximetry values
• B. A bright light in the client's face may cause a low pulse oximetry
• C. External light sources may cause falsely low oximetry values
• D. The client needs a dark and quiet room to recover and maintain proper oxygenation

Correct answer: A

Rationale: When assessing a client's pulse oximetry values, the nurse should turn off any extra environmental lights that are unnecessary, including exam lights or over-bed lights. External light sources may cause falsely high oximetry values when the extra light interferes with the sensor of the oximeter, leading to inaccurate readings. Choice B is incorrect because a bright light in the client's face would not directly affect the pulse oximetry values. Choice C is incorrect as external light sources typically cause falsely high, not low, oximetry values. Choice D is incorrect as the primary reason for turning off the light is to prevent falsely high readings, not solely for the client's comfort.

3. A client with schizophrenia is taking loxapine. Which of the following findings should the nurse identify as the most important to report?

• A. Spasms of the tongue and face
• B. Orthostatic hypotension
• C. Dry mouth
• D. Increased appetite

Correct answer: A

Rationale: Spasms of the muscles of the tongue, face, neck, and back are indicative of acute dystonia, an extrapyramidal manifestation associated with loxapine use. Acute dystonia is a serious condition that can lead to airway obstruction and respiratory compromise. Therefore, the nurse should prioritize reporting this finding to prevent potential harm to the client. Orthostatic hypotension, dry mouth, and increased appetite are common side effects of antipsychotic medications but are not as immediately life-threatening as acute dystonia. Monitoring and managing these side effects are essential for the client's overall well-being, but they do not pose the same level of urgency as addressing acute dystonia.

4. When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?

• A. A normal reading
• B. An abnormally low reading
• C. An abnormally high reading
• D. A fluctuating reading

Correct answer: B

Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.

5. The chain of infection includes the ________________.

• A. germ, agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host
• B. active natural, active artificial, passive natural, and passive artificial
• C. opportunism, weakness, immunity, and colonization
• D. intrinsic, extrinsic, internal, and external transmission

Correct answer: A

Rationale: The chain, or cycle, of infection includes the germ (microorganism), agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host. This sequence describes how infections are passed from one person to another. Choice B is incorrect because it refers to types of immunity, not components of the chain of infection. Choice C is also incorrect as it lists terms unrelated to the chain of infection. Choice D is incorrect as it describes transmission types, not components of the chain of infection. Understanding the chain of infection is crucial in preventing the spread of infections by breaking one or more links in the chain, such as interrupting the mode of transmission through proper hand hygiene.

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