Nursing Elites

1. Why should a palpated pressure be performed before auscultating blood pressure?

• A. To more clearly hear the Korotkoff sounds.
• B. To detect the presence of an auscultatory gap.
• C. To avoid missing a falsely elevated blood pressure.
• D. To more readily identify phase IV of the Korotkoff sounds.

Correct answer: B

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.

2. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

• A. 240 cc
• B. 120 cc
• C. 8 cc
• D. 0 cc because Italian ice is not a fluid

Correct answer: A

Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.

3. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?

• A. Cataracts
• B. Glaucoma
• C. Astigmatism
• D. Presbyopia

Correct answer: D

Rationale: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.

4. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

• A. The child is asked to undress from the waist up.
• B. The head is examined before the thorax, abdomen, and genitalia.
• C. The nurse should keep in mind that a child at this age will have a sense of modesty.
• D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.

Correct answer: C

Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.

5. Which is the most effective action for controlling the spread of infection?

• A. Thorough hand hygiene
• B. Wearing gloves and masks when providing direct client care
• C. Implementing appropriate isolation precautions
• D. Administering broad-spectrum prophylactic antibiotics

Correct answer: A

Rationale: Thorough hand hygiene is the most effective action for controlling the spread of infection as hands are a common source of transmission. Regular and routine hand hygiene helps prevent the movement of potentially infective materials. Wearing gloves and masks is important when providing direct client care to protect both the caregiver and the patient, but it is not as effective as thorough hand hygiene in preventing overall infection spread. Implementing appropriate isolation precautions is necessary for clients with known communicable diseases, but it is not as universally effective in preventing the spread of various infections. Administering broad-spectrum prophylactic antibiotics is not an appropriate measure for controlling the spread of infection as routine use can lead to superinfection and the development of resistant organisms.

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