Nursing Elites

1. A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?

• A. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
• B. The patient should be directed to walk around the room and his blood pressure assessed after this activity.
• C. Blood pressure and pulse are assessed at the beginning and at the end of the examination.
• D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.

Correct answer: A

Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive medications, when the person reports fainting or syncope, or when volume depletion is suspected. The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.

2. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?

• A. Interpret that the patient is eager and interested in participating in the interview.
• B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
• C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
• D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.

Correct answer: D

Rationale: Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.

3. What is the purpose of MSDS sheets?

• A. Contain the ordering information for each piece of equipment in the office.
• B. Are required by OSHA to be accessible to all employees of the office.
• C. Can be used to treat patients who have been injured in equipment accidents.
• D. None of the above.

Correct answer: B

Rationale: MSDS sheets, also known as Materials Safety Data Sheets, are essential documents that provide detailed information about chemicals used in the workplace. They are required by OSHA to be easily accessible to all employees to ensure they have the necessary information to handle chemicals safely. MSDS sheets do not contain ordering information for equipment in the office (Choice A) or serve as a treatment guide for injured patients (Choice C). Therefore, the correct answer is that MSDS sheets are required by OSHA to be accessible to all employees of the office.

4. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?

• A. Incomplete data
• B. Generalizing from experience
• C. Identifying with the client
• D. Lack of clinical experience

Correct answer: A

Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning. Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions. Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.

5. A client is being instructed on how to use crutches. Which of the following information should be included in the teaching?

• A. Place the majority of body weight on the axilla.
• B. Dry crutch tips with a paper towel if they become wet.
• C. Use the crutches for support to lift both feet simultaneously when ascending stairs.
• D. Both B and C.

Correct answer: B

Rationale: When instructing a client on how to use crutches for ambulation, it is important to emphasize keeping the crutch tips dry to prevent slipping while bearing weight on them. Moisture on the crutch tips can lead to accidents. Therefore, the correct answer is to dry the crutch tips with a paper towel if they become wet. Choice A, placing the majority of body weight on the axilla, is incorrect as the weight should be borne through the hands, not the axilla, to avoid nerve damage. Choice C, using the crutches to lift both feet simultaneously when ascending stairs, is incorrect as the client should ascend stairs by placing weight on the unaffected leg first, followed by the crutches and then the affected leg. This method provides stability and safety during stair climbing.

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