Nursing Elites

1. Mobility is an important human function. The hazards of immobility lead to many physical and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin, and emotional changes. Which of the following is an example of a skeletal hazard of immobility?

• A. Contractures.
• B. Constipation.
• C. Calcium loss.
• D. Catabolism.

Correct answer: C

Rationale: All choices are hazards of immobility, but only calcium loss from the bones is a skeletal system impairment that results from immobility. Contractures are muscle shortening due to prolonged positioning, which affects the muscular system. Constipation is a gastrointestinal issue. Catabolism is a metabolic process, not specific to the skeletal system.

2. When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?

• A. A normal reading
• B. An abnormally low reading
• C. An abnormally high reading
• D. A fluctuating reading

Correct answer: B

Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.

3. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

• A. Altered tissue perfusion
• B. Risk for fluid volume deficit
• C. High risk for hemorrhage
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.

4. Which of the following is an example of whistle-blowing?

• A. A nurse contacts administration about a colleague who takes supplies to use for a mission trip
• B. A client sues a nurse because she failed to call the physician about his wound infection
• C. A nursing assistant calls for help when a client falls out of bed
• D. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours

Correct answer: A

Rationale: Whistle-blowing involves notifying administration or a supervisor about unethical or illegal activities. In this scenario, the nurse reporting a colleague taking supplies for personal use is an example of whistle-blowing as it involves reporting behavior that is dishonest and potentially harmful. Choices B, C, and D do not represent whistle-blowing. Choice B involves a legal action by a client against a nurse, choice C is a situation where immediate care is provided, and choice D is a case of neglect that should have been prevented.

5. Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?

• A. Kussmaul respirations
• B. Cheyne-Stokes respirations
• C. Biot's respirations
• D. Cluster breathing

Correct answer: A

Rationale: Mr. N is most likely exhibiting Kussmaul respirations. Kussmaul respirations are a form of hyperventilation associated with conditions like metabolic acidosis. They are characterized by rapid, regular, and deep breathing. This type of respiratory pattern helps the body compensate for metabolic acidosis by attempting to blow off excess carbon dioxide. This pattern is different from Cheyne-Stokes respirations (choice B), which are characterized by alternating periods of deep, rapid breathing followed by apnea. Biot's respirations (choice C) are characterized by groups of quick, shallow inspirations followed by irregular periods of apnea, and Cluster breathing (choice D) involves clusters of breaths followed by periods of apnea, often seen in patients with brain injury or neurological conditions.

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