Nursing Elites

1. In taking the client’s blood pressure, the nurse should position the client’s arm:

• A. At the level of the heart
• B. Slightly above the level of the heart
• C. At the 5th intercostals space midclavicular line
• D. Below the level of the heart

Correct answer: A

Rationale: Proper patient positioning is essential for maximizing lung expansion and promoting the drainage of secretions. Postural drainage techniques rely on gravity to help clear different lung segments, which is critical in preventing complications such as atelectasis or pneumonia in immobilized patients.

2. Muscle weakness due to wasting would most likely be evaluated by which test?

• A. recall of food intake
• B. skinfold thickness
• C. handgrip strength
• D. red blood cell levels

Correct answer: C

Rationale: Handgrip strength is a reliable test to assess muscle function and detect muscle weakness due to wasting. It is often used to identify conditions like sarcopenia in clinical settings. Options A, B, and D are not suitable for evaluating muscle weakness. Food intake recall does not directly measure muscle function, skinfold thickness assesses body fat but not muscle strength, and red blood cell levels are unrelated to muscle wasting.

3. Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the following is the best nursing intervention to prevent future falls?

• A. Tell Angie not to get up from bed unassisted
• B. Put the call bell within her reach
• C. Put bedside commode at the bedside to prevent Angie from getting up
• D. Put the bed in the lowest position ever

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

4. Membership dropout generally occurs in group therapy after a member:

• A. Accomplishes his goal in joining the group
• B. Discovers that his feelings are shared by the group members
• C. Experiences feelings of frustration in the group
• D. Discusses personal concerns with group members

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. What is the most likely complication for a client receiving TPN who suddenly develops tremors, dizziness, and diaphoresis?

• A. Fluid volume overload
• B. Sepsis
• C. Hyperglycemia
• D. Hypoglycemia

Correct answer: D

Rationale: The correct answer is D, Hypoglycemia. When a client receiving TPN suddenly develops tremors, dizziness, and diaphoresis, it is indicative of hypoglycemia. TPN provides a high concentration of glucose, and if it is abruptly stopped or the infusion rate is reduced, it can lead to hypoglycemia. Choices A, B, and C are incorrect as they do not directly correlate with the symptoms described in the scenario. Fluid volume overload typically presents with edema and hypertension, sepsis with fever and increased heart rate, and hyperglycemia with polyuria, polydipsia, and blurred vision.

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