Nursing Elites

1. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

• A. Take the blood pressure reading on both arms for comparison
• B. Listen to and identify the phases of Korotkoff sounds
• C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
• D. Observe procedures for infection control

Correct answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

2. A nurse is teaching an in-service about manifestations of hypoglycemia to a group of newly licensed nurses. Which of the following should the nurse include in the teaching?

• A. Blurred vision
• B. Vomiting
• C. Kussmaul respirations
• D. Bradycardia

Correct answer: A

Rationale: Corrected Rationale: Blurred vision is a common symptom of hypoglycemia and should be included in the teaching. Other manifestations like vomiting, Kussmaul respirations, and bradycardia are not typically associated with hypoglycemia. Vomiting is more commonly seen in conditions like food poisoning or gastrointestinal issues. Kussmaul respirations are deep and rapid respirations seen in metabolic acidosis, not hypoglycemia. Bradycardia is usually not a manifestation of hypoglycemia; tachycardia is more commonly associated with low blood sugar levels.

3. A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription which reads, 'Discontinue NPO status; advance diet as tolerated.' Which of the following are appropriate for the nurse to offer the client? (SATA)

• A. Wheat toast
• B. Applesauce
• C. Applesauce, Chicken broth
• D. Chicken broth

Correct answer: C

Rationale: The correct answer is C: Applesauce and chicken broth. After an appendectomy, patients are typically started on a clear liquid diet before advancing to more solid foods. Applesauce and chicken broth are part of a low-residue diet that is easily digestible and gentle on the digestive system, making them suitable choices for a client following surgery. Wheat toast may be too heavy and fibrous initially, while other solid foods should be introduced gradually to prevent gastrointestinal upset.

4. The nurse is planning education about appropriate protein food choices for a client who has recently been prescribed a renal diet. Which protein food items should the nurse include in the education?

• A. Yogurt, seeds, and lentils
• B. Beef, bacon, and nuts
• C. Peanut butter, beans, and peas
• D. Poultry, eggs, and fish

Correct answer: D

Rationale: The correct answer is D: Poultry, eggs, and fish. These protein sources are high-quality proteins suitable for a renal diet as they provide essential amino acids without excessive amounts of potassium or phosphorus. Choice A, yogurt, seeds, and lentils, may be high in potassium and phosphorus, which could be restricted in a renal diet. Choice B, beef, bacon, and nuts, are also high in phosphorus and may not be ideal for a renal diet. Choice C, peanut butter, beans, and peas, are high in potassium and phosphorus, making them less suitable for a renal diet.

5. Is it correct that eliminating sucrose from the diet leads to a significant reduction in dental caries, and that the best advice is to consume sugar in moderation and limit the frequency of sugar exposure?

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true; the second is false
• D. The first statement is false; the second is true

Correct answer: D

Rationale: The first statement is incorrect because dental caries are not solely caused by sucrose. They are the result of a complex interaction of multiple factors, including the type of bacteria in the mouth, the host's diet, oral hygiene, and salivary flow. The second statement is correct as consuming sugar in moderation and limiting the frequency of sugar exposure are indeed effective strategies to prevent dental caries. Therefore, the answer is option D: The first statement is false; the second is true.

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