Nursing Elites

1. The healthcare professional notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

• A. Yield a falsely low blood pressure
• B. Yield a falsely high blood pressure
• C. Be the same, regardless of cuff size
• D. Vary as a result of the technique of the person performing the assessment

Correct answer: B

Rationale: Using a cuff that is too narrow for an obese patient would likely yield a falsely high blood pressure reading. This occurs because the standard cuff is too small for the arm's circumference, requiring more pressure to compress the artery. A tight cuff can lead to inaccurate and elevated blood pressure readings. Choices A, C, and D are incorrect because using an improperly sized cuff would not yield a falsely low blood pressure, the blood pressure reading does vary with cuff size, and the technique of the person performing the assessment is not the primary factor affecting the reading in this situation.

2. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to:

• A. Give the client orientation materials and review the unit rules and regulations.
• B. Introduce him/her and accompany the client to the client's room.
• C. Take the client to the day room and introduce him/her to the other clients.
• D. Ask the nursing assistant to get the client's vital signs and complete the admission search.

Correct answer: B

Rationale: Anxiety is triggered by change that threatens the individual's sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. The correct initial response is to introduce the client and accompany them to their room. This approach helps the client feel oriented, safe, and supported. Giving orientation materials or reviewing rules and regulations may overwhelm the client further. Taking the client to the day room and introducing them to other clients could increase anxiety by exposing them to unfamiliar faces. Asking the nursing assistant to get vital signs and complete admission tasks can wait until the client feels more settled and secure in their environment.

3. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?

• A. This too shall pass.
• B. Take the child immediately to the ER
• C. Contact the Poison Control Center quickly
• D. Give the child syrup of ipecac

Correct answer: C

Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.

4. Patients who cannot move in their bed on their own should be turned at least ________________.

• A. once a day
• B. twice a day
• C. every 2 hours
• D. every 4 hours

Correct answer: C

Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.

5. When performing CPR, at what rate should chest compressions be applied?

• A. 100 per minute
• B. 60 per minute
• C. As quickly as possible
• D. 200 per minute

Correct answer: A

Rationale: During CPR, chest compressions should be applied at a rate of 100 compressions per minute in order to effectively circulate blood and oxygen to vital organs. Option A, '100 per minute,' is the correct answer as it aligns with the recommended compression rate in CPR guidelines. Option B, '60 per minute,' is incorrect as it is too slow and may not provide adequate circulation. Option C, 'As quickly as possible,' is vague and does not specify the recommended compression rate. Option D, '200 per minute,' is incorrect as it exceeds the recommended rate and may not be as effective in maintaining perfusion.

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