Nursing Elites

1. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

2. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?

• A. Encourage the client to use a nicotine patch.
• B. Reassure the client that it is almost time for another break.
• C. Have the client leave the unit with another staff member.
• D. Review the schedule of outdoor breaks with the client.

Correct answer: D

Rationale: When a client becomes angry while waiting for a supervised break, it is essential to address their concerns effectively. Reviewing the schedule of outdoor breaks with the client provides concrete information, helps manage the client's expectations, and may alleviate their frustration. This intervention promotes transparency and empowers the client by clarifying the timing of their desired break, fostering a therapeutic and collaborative nurse-client relationship. Encouraging the client to use a nicotine patch (Choice A) does not address the client's immediate frustration with the break schedule. Reassuring the client about another break (Choice B) may temporarily placate them but does not address the underlying issue. Having the client leave the unit with another staff member (Choice C) may not be feasible or appropriate at that moment and does not address the client's concerns.

3. After insertion of the indwelling catheter, how should the nurse position the drainage container?

• A. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
• B. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
• C. At the head of the bed for easy and accurate measurement of urine.
• D. Beside the patient in their bed to avoid embarrassment.

Correct answer: B

Rationale: The correct position for the drainage container after inserting an indwelling catheter is to have it placed lower than the bladder. This positioning helps maintain a constant downward flow of urine from the bladder, preventing backflow and ensuring proper drainage. Choice A is incorrect because having the drainage tubing taut does not promote proper urine flow and may cause kinking. Choice C is incorrect as placing the container at the head of the bed does not affect drainage and is not necessary for accurate measurement. Choice D is incorrect as the positioning of the drainage container should prioritize proper drainage and care over potential embarrassment.

4. What is the most effective way to implement a teaching plan?

• A. Teach the information that the learner wants to learn first.
• B. Streamline the teaching plan to include only essential information.
• C. Present to the learner all the necessary information to meet the objectives.
• D. Provide the learner with written material to review before teaching sessions.

Correct answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.

5. After ensuring correct tube placement, what action should the nurse take next when administering medications through a nasogastric tube (NGT) connected to suction?

• A. Clamp the tube for 20 minutes.
• B. Flush the tube with water.
• C. Administer the medications as prescribed.
• D. Crush the tablets and dissolve in sterile water.

Correct answer: B

Rationale: After ensuring the correct placement of the NGT, the nurse should flush the tube with water to prevent any obstructions and ensure proper medication delivery. Flushing the tube is essential before, after, and in between each medication administration. Clamping the tube for 20 minutes should be done after all medications are administered to prevent clogging. Administering medications as prescribed and preparing medications by crushing tablets and dissolving them in sterile water should only be done after the tube has been appropriately flushed to maintain its patency and effectiveness.

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