Nursing Elites

1. Theresa, a mother with a 2-year-old daughter, asks, 'At what age can I start taking my daughter's blood pressure as a routine procedure, since hypertension is common in our family?' What would your answer be?

• A. At 2 years old, you may
• B. As early as 1 year old
• C. When she's 3 years old
• D. When she's 6 years old

Correct answer: D

Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.

2. Gina, A client in prolong labor said she cannot go on anymore. The health care team decided that both the child and the mother cannot anymore endure the process. The baby is premature and has a little chance of surviving. Caesarian section is not possible because Gina already lost enough blood during labor and additional losses would tend to be fatal. The husband decided that Gina should survive and gave his consent to terminate the fetus. The principle that will be used by the health care team is:

• A. Beneficence
• B. Non malfeasance
• C. Justice
• D. Double effect

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

• A. Client lying on his back then flat on his abdomen on Trendelenburg position
• B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his
• C. Client lying flat on his back and then flat on his abdomen
• D. Client lying on his right then left side on Trendelenburg position

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

4. A patient is on a low-sodium diet. Which food item should the patient avoid?

• A. Fresh fruit
• B. Canned soup
• C. Whole grain bread
• D. Grilled chicken

Correct answer: B

Rationale: The correct answer is B: Canned soup. Canned soup is commonly high in sodium content, which is not suitable for a patient on a low-sodium diet. Fresh fruit, whole grain bread, and grilled chicken typically have lower sodium levels and can be included in a low-sodium diet. Therefore, the patient should avoid canned soup to adhere to the requirements of a low-sodium diet.

5. The nurse’s most unique tool in working with the emotionally ill client is his/her

• A. theoretical knowledge
• B. personality make up
• C. emotional reactions
• D. communication skills

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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