Nursing Elites

1. The healthcare provider is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?

• A. A review in the Cochrane Library.
• B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL).
• C. An online nursing textbook.
• D. The policy and procedure manual at the healthcare agency.

Correct answer: A

Rationale: The Cochrane Library provides systematic reviews of primary research in healthcare, making it a reliable resource for evidence-based practice. Choice B, a literature search in a database like CINAHL, may also be useful but does not guarantee the same level of systematic review and reliability as the Cochrane Library. Choice C, an online nursing textbook, may offer information but might not provide the most current or evidence-based practices. Choice D, the policy and procedure manual at the healthcare agency, is unlikely to offer the comprehensive evidence-based information needed for developing standards of care.

2. Which of the following symptoms would a healthcare provider expect to find in a patient with hyperkalemia?

• A. Muscle cramps.
• B. Hypertension.
• C. Bradycardia.
• D. Tachycardia.

Correct answer: D

Rationale: Tachycardia is the correct symptom to expect in a patient with hyperkalemia. Hyperkalemia, or high potassium levels in the blood, can affect the electrical activity of the heart. Increased potassium levels can lead to changes in the heart's rhythm, potentially causing tachycardia (rapid heart rate) or other cardiac arrhythmias. Muscle cramps (choice A) are not typically associated with hyperkalemia. Hypertension (choice B) is not a common symptom of hyperkalemia; in fact, high potassium levels can sometimes cause low blood pressure. Bradycardia (choice C), or a slow heart rate, is usually not a primary symptom of hyperkalemia; instead, hyperkalemia tends to be associated with faster heart rates or arrhythmias.

3. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.

• A. Measuring the BP after the client has sat quietly for 5 minutes
• B. Having the client sit with the arm bared and supported at heart level
• C. Using a cuff with a rubber bladder that encircles less than 80% of the limb
• D. Measuring the BP after the client reports that he just drank a cup of coffee

Correct answer: C

Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.

4. A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to:

• A. Prevent the client from getting a nosebleed
• B. Give the client added fluid by way of the respiratory tree
• C. Humidify the oxygen that is bypassing the client’s nose
• D. Prevent fluid loss from the lungs during mouth breathing

Correct answer: C

Rationale: The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing. When a client breathes through the mouth, the oxygen delivered by the face mask bypasses the natural humidification provided by the nasal passages. Therefore, the water bottle attachment helps to add moisture to the oxygen, preventing dryness and irritation to the respiratory tract. Choices A, B, and D are incorrect. Clients breathing through the mouth are not at risk for nosebleeds, do not receive added fluid through the respiratory tree, and do not experience fluid loss from the lungs due to mouth breathing.

5. What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?

• A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
• B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
• C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
• D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.

Correct answer: C

Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.

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