Nursing Elites

1. What is the primary role of the sinoatrial (SA) node in the heart?

• A. Pacemaker of the heart
• B. Blood pressure regulation
• C. Electrical conduction delay
• D. Stimulating muscle contraction

Correct answer: A

Rationale: The correct answer is A: Pacemaker of the heart. The SA node, known as the natural pacemaker, initiates the electrical impulses that set the rhythm for the heartbeat. It is responsible for coordinating the heart's contractions by generating electrical signals at regular intervals. Choice B is incorrect as the SA node's primary function is not related to blood pressure regulation. Choice C is incorrect as the SA node does not cause electrical conduction delay but rather initiates and conducts the electrical impulses. Choice D is incorrect as the SA node does not directly stimulate muscle contraction but rather initiates the electrical events that lead to muscle contraction.

2. A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?

• A. Apply an ice pack to the incision site.
• B. Monitor the client's temperature.
• C. Document the findings and continue to monitor.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.

3. A dispersion consists of a solute dispersed through a dispersing vehicle. Which of the following dispersions is a liquid for topical application that contains insoluble solids or liquids?

• A. Ointment
• B. Lotion
• C. Paste
• D. Gel

Correct answer: B

Rationale: The correct answer is B, 'Lotion.' A lotion is a liquid dispersion that contains insoluble solids or liquids for topical application. Ointments are more semi-solid and occlusive, pastes are thicker and contain higher concentrations of solids, and gels have a jelly-like consistency due to their three-dimensional network structure. Therefore, among the options, a lotion is the most suitable choice for containing insoluble solids or liquids for topical application.

4. A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?

• A. Keep the client's extremities cold
• B. Check for strength and symmetry of peripheral pulses
• C. Keep the client's legs elevated
• D. Monitor for any constrictions, such as clothes or covers that are too tight around the legs

Correct answer: A

Rationale: Keeping the client’s extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.

5. What intervention should the PN implement when taking the rectal temperature of an adult client?

• A. Lubricate the tip of the thermometer with a water-based gel.
• B. Gently insert the thermometer 1 inch into the rectum.
• C. Hold the thermometer in place the entire time while taking the temperature.
• D. Place the client in the left lateral position.

Correct answer: C

Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.

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