Nursing Elites

1. When initiating cardiopulmonary resuscitation (CPR), what assessment finding must the healthcare provider confirm before beginning chest compressions?

• A. Absence of a pulse
• B. Presence of a pulse
• C. Respiratory rate
• D. Blood pressure

Correct answer: A

Rationale: The correct answer is A: Absence of a pulse. Prior to initiating chest compressions during CPR, it is essential to confirm the absence of a pulse. Chest compressions are indicated when there is no detectable pulse as it signifies cardiac arrest. Checking for a pulse is a critical step to ensure that CPR is performed on individuals who truly require it. Choices B, C, and D are incorrect because focusing on the presence of a pulse, respiratory rate, or blood pressure before starting chest compressions can delay life-saving interventions in a person experiencing cardiac arrest.

2. During a home safety assessment for a client receiving supplemental oxygen, which observation should the nurse identify as proper safety protocol?

• A. The client uses non-acetone nail polish remover.
• B. The client uses an electric razor for shaving.
• C. The client cleans their oxygen equipment weekly.
• D. The client uses wool blankets.

Correct answer: A

Rationale: The correct answer is A. Using non-acetone nail polish remover is crucial for clients on supplemental oxygen as acetone is flammable and poses a safety risk. Acetone can react with oxygen, increasing the fire hazard. Choices B, C, and D are incorrect. Electric razors can generate sparks, which are dangerous near oxygen due to the risk of ignition. While cleaning oxygen equipment is important, the type of nail polish remover used is more critical for immediate safety. Wool blankets can create static electricity, increasing the risk of fire around oxygen due to its flammability.

3. The healthcare professional is evaluating the body alignment of a patient in the sitting position. Which observation will indicate a normal finding?

• A. The edge of the seat is making contact with the popliteal space.
• B. Both feet are supported on the floor with ankles flexed.
• C. The body weight is solely on the buttocks.
• D. The arms hang comfortably at the sides.

Correct answer: B

Rationale: In a normal sitting position, both feet should be supported on the floor with the ankles comfortably flexed. This position helps in maintaining stability and proper alignment. Choice A is incorrect because the edge of the seat pressing against the popliteal space may cause discomfort and is not indicative of proper alignment. Choice C is incorrect as the body weight should be evenly distributed for proper alignment and comfort, not solely on the buttocks. Choice D is incorrect as the position of the arms alone does not indicate proper body alignment in the sitting position; proper arm positioning is important for comfort but not a key indicator of body alignment.

4. A client who is 3 days post-op following a cholecystectomy has yellow and thick drainage on the dressing. The nurse suspects a wound infection. The nurse identifies this type of drainage as:

• A. Purulent
• B. Serous
• C. Sanguineous
• D. Serosanguineous

Correct answer: A

Rationale: The correct answer is A: Purulent. Purulent drainage is thick, yellow, and indicates the presence of infection. This type of drainage is typically seen in infected wounds. Choice B, Serous drainage, is thin, clear, and watery, which is normal in the initial stages of wound healing. Sanguineous drainage, choice C, is bright red and indicates fresh bleeding. Serosanguineous drainage, choice D, is pale pink to red and is a mixture of blood and serous fluid commonly seen in the early stages of wound healing.

5. A healthcare professional is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the healthcare professional take?

• A. Place the bladder of the cuff over the posterior aspect of the thigh
• B. Use a smaller cuff designed for lower extremities
• C. Place the cuff around the client's ankle
• D. Ensure the cuff is positioned above the knee

Correct answer: A

Rationale: When measuring blood pressure in the lower extremity, the bladder of the cuff should be placed over the posterior aspect of the thigh. This positioning ensures an accurate measurement. Placing the cuff around the ankle (Choice C) or above the knee (Choice D) would not provide an accurate blood pressure reading in the lower extremity. Using a smaller cuff designed for lower extremities (Choice B) is not appropriate as the standard cuff size should be used with the bladder placed over the posterior aspect of the thigh.

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