Nursing Elites

1. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

• A. Diastolic blood pressure may not be heard.
• B. Diastolic blood pressure may be falsely low.
• C. Systolic blood pressure may be falsely low.
• D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

2. A client is being transferred from a bed to a wheelchair. Which action is essential to maintain client safety in this situation?

• A. Position the wheelchair at the foot of the bed
• B. Maintain a space of at least 12 inches between the wheelchair and the bed
• C. Place the footplates in the lowest position before transferring the client
• D. Lock both wheels on the wheelchair before moving the client

Correct answer: D

Rationale: When transferring a client from a bed to a wheelchair, it is crucial to prioritize client safety. Locking both wheels on the wheelchair before moving the client is essential as it adds stability and prevents the wheelchair from moving unexpectedly during the transfer process. Placing the wheelchair at the foot of the bed allows for easier transfer, but ensuring the wheels are locked is more critical for safety. Maintaining a 12-inch space between the wheelchair and the bed is not as essential as ensuring wheel locks are engaged. While placing the footplates in the lowest position can enhance client comfort, it is not a safety measure that is as critical as securing the wheelchair by locking its wheels before the transfer.

3. A patient is seen in the clinic for reports of "fainting episodes that started last week."? How would the nurse proceed with the examination?

• A. Blood pressure readings are taken in both arms and thighs.
• B. The patient is assisted to a lying position, and their blood pressure is taken.
• C. The patient's blood pressure is recorded in lying, sitting, and standing positions.
• D. The patient's blood pressure is recorded in lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.

Correct answer: C

Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure. Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.

4. A physician's order instructs a nurse to take a temperature at the axilla. Where would the nurse place the thermometer?

• A. In the rectum
• B. In the mouth
• C. On the temples
• D. In the armpit

Correct answer: A

Rationale: When a physician's order specifies taking a temperature at the axilla, the nurse should place the thermometer in the armpit. The axilla is the anatomical area of the armpit located under the arms, proximal to the trunk. Placing the thermometer in the rectum (Choice A) is used for rectal temperature measurements, in the mouth (Choice B) for oral temperature measurements, and on the temples (Choice C) is not a common site for temperature assessment. Therefore, the correct placement based on the given instruction is in the armpit.

5. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.

• A. Imbalanced nutrition: Less than body requirements
• B. Chronic low self-esteem
• C. Risk for suicide
• D. Hopelessness

Correct answer: B

Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.

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