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. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

• A. Maintain the client in a lateral position using protective wrist and vest restraints.
• B. Position the client prone with a small pillow below the diaphragm.
• C. Raise the head and knee gatch when lying in a supine position.
• D. Transfer the client to a wheelchair close to the nursing station for observation.

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

3. A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which intervention should the nurse implement first?

• A. Administer bronchodilators as prescribed.
• B. Administer oxygen via nasal cannula.
• C. Encourage the client to cough and deep breathe.
• D. Position the client in high Fowler's position.

Correct answer: B

Rationale: Administering oxygen via nasal cannula (B) is the priority intervention for a client with COPD exacerbation to improve oxygenation. In COPD exacerbation, there is impaired gas exchange leading to hypoxemia, making oxygen therapy the initial priority. Administering bronchodilators (A) helps with bronchodilation but should come after ensuring adequate oxygenation. Encouraging coughing and deep breathing (C) and positioning the client in high Fowler's position (D) are also beneficial interventions, but the first step is to address the oxygenation needs of the client.

4. A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?

• A. The Patient's Bill of Rights protects clients from malicious intents, so the healthcare professional could lose the case.
• B. The lawsuit may be settled out of court, but the healthcare professional's license is likely to be revoked.
• C. There will be no judgment against the healthcare professional, whose actions were protected under the Good Samaritan Act.
• D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

Correct answer: C

Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. In this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act. Choice A is incorrect because the situation does not involve the Patient's Bill of Rights, but rather the Good Samaritan Act. Choice B is incorrect as the license revocation is not a typical outcome in Good Samaritan cases. Choice D is incorrect as the Good Samaritan Act provides immunity from liability in such emergency situations.

5. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

• A. Check for a blood return.
• B. Reposition the client's arm.
• C. Remove the IV site dressing.
• D. Flush the lock with saline.

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

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