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. Which of the following tests would MOST LIKELY be performed on a patient who is being monitored for coagulation therapy?

• A. PT/INR
• B. CBC
• C. PTT
• D. WBC

Correct answer: A

Rationale: The correct answer is A: PT/INR. Prothrombin times (PT/INR) are commonly used to monitor patients on Coumadin (warfarin) therapy, an anticoagulant that slows the blood's ability to clot. Monitoring PT/INR levels helps ensure the patient is receiving the appropriate dosage of Coumadin. Choice B, CBC (Complete Blood Count), is a general test that provides information on red blood cells, white blood cells, and platelets but is not specific to monitoring coagulation therapy. Choice C, PTT (Partial Thromboplastin Time), is another coagulation test but is not as commonly used for monitoring Coumadin therapy. Choice D, WBC (White Blood Cell count), is unrelated to monitoring coagulation therapy and is used to assess immune system function.

3. A physician asks you to place the patient with his dorsal side facing the exam table. Which of the following accurately describes how the patient is positioned?

• A. The patient is lying prone.
• B. The patient is lying supine.
• C. The patient is lying in the recovery position.
• D. The patient is lying on his stomach.

Correct answer: B

Rationale: When the physician asks for the patient to be placed with their dorsal side facing the exam table, it means the patient should be lying on their back. This position is known as the supine position, where the patient's back is on the table, facing up towards the ceiling. Choice A, 'The patient is lying prone,' is incorrect as the prone position is when the patient is lying face down. Choice C, 'The patient is lying in the recovery position,' is incorrect as the recovery position is a lateral position typically used in first aid. Choice D, 'The patient is lying on his stomach,' is incorrect as it describes the prone position, not the supine position as required in this scenario.

4. A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?

• A. Administer the feeding as ordered
• B. Pull the feeding tube out approximately 3 cm
• C. Flush the feeding tube with 60 cc of water
• D. Contact the physician

Correct answer: A

Rationale: When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.

5. A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?

• A. Bending the leg at the knee
• B. Turning the foot inward and outward
• C. Moving the leg in a circle
• D. Moving the leg forward and up

Correct answer: C

Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.

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