Nursing Elites

1. During a general survey of a patient, which finding is considered normal?

• A. Body mass index (BMI) of 20.
• B. When standing, the patient's base is narrow.
• C. The patient appears older than their stated age.
• D. Arm span (fingertip to fingertip) is greater than the height.

Correct answer: A

Rationale: A body mass index (BMI) of 20 is considered normal as the range for a normal BMI is between 19-24. When standing, a patient's base should be wide for stability and proper weight distribution. An older appearance than the stated age may indicate a history of chronic illness or chronic alcoholism. In a general survey, the patient's arm span (fingertip to fingertip) should approximately equal the patient's height. An arm span greater than the height may suggest Marfan syndrome. Therefore, the correct choice is a normal BMI of 20, which falls within the healthy range. Choices B, C, and D all describe abnormal findings that may indicate underlying health conditions or syndromes.

2. While measuring a patient's blood pressure, which factor influences a patient's blood pressure?

• A. Pulse rate
• B. Pulse pressure
• C. Vascular output
• D. Peripheral vascular resistance

Correct answer: D

Rationale: When measuring a patient's blood pressure, it is important to consider various factors that influence blood pressure. Peripheral vascular resistance plays a crucial role in regulating blood pressure. The level of blood pressure is affected by factors such as cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. Pulse rate (Choice A) refers to the number of heartbeats per minute and is not a primary factor influencing blood pressure. Pulse pressure (Choice B) is the difference between systolic and diastolic blood pressure and does not directly impact blood pressure regulation. Vascular output (Choice C) is not a recognized term in blood pressure regulation and is not a primary factor affecting blood pressure.

3. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

• A. These readings are a normal response and attributable to changes in the patient's position.
• B. The change in blood pressure readings is called orthostatic hypotension.
• C. The blood pressure reading in the lying position is within normal limits.
• D. The change in blood pressure readings is considered within normal limits for the patient's age.

Correct answer: B

Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of �20 mm Hg or �10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.

4. Intermittent fevers are:

• A. fevers which come and go.
• B. fevers which rise and fall but are always considered above the patient's average temperature.
• C. fevers which fluctuate more than three degrees and never return to normal.
• D. None of the above.

Correct answer: A

Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.

5. When providing endotracheal suctioning, for how long should the nurse suction the endotracheal tube of an intubated client on a ventilator at a time?

• A. Five seconds or less
• B. Ten seconds or less
• C. At least 30 seconds
• D. No longer than 60 seconds

Correct answer: B

Rationale: When providing endotracheal suctioning, the nurse should suction for no longer than ten seconds at a time. Suctioning for longer than ten seconds may cause hypoxia or bronchospasm. Extended suctioning may also place the client at risk of injury to the bronchial and tracheal structures. Choices C and D suggest prolonged suctioning durations that can lead to adverse effects on the client. Choice A, suctioning for five seconds or less, may not be adequate to clear secretions effectively, making choice B the most appropriate duration for safe and efficient suctioning in this scenario.

Similar Questions