Nursing Elites

1. Theresa, a mother with a 2-year-old daughter, asks, 'At what age can I start taking my daughter's blood pressure as a routine procedure, since hypertension is common in our family?' What would your answer be?

• A. At 2 years old, you may
• B. As early as 1 year old
• C. When she's 3 years old
• D. When she's 6 years old

Correct answer: D

Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.

2. After a vaginal examination, the nurse determines that the client’s fetus is in an occiput posterior position. The nurse would anticipate that the client will have:

• A. A precipitous birth
• B. Intense back pain
• C. Frequent leg cramps
• D. Nausea and vomiting

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. A nurse is reviewing blood glucose values for a client who is at risk for Diabetes Mellitus. Which of the following findings should the nurse report to the provider?

• A. 2-hour glucose tolerance test level 150 mg/dL
• B. Fasting blood glucose 70 mg/dL
• C. Glycosylated hemoglobin 5%
• D. Casual blood glucose 90 mg/dL

Correct answer: A

Rationale: The correct answer is A. A 2-hour glucose tolerance test level of 150 mg/dL is above the normal range and should be reported to the provider as it indicates impaired glucose tolerance. Choice B (Fasting blood glucose 70 mg/dL) is within the normal range. Choice C (Glycosylated hemoglobin 5%) is also within the normal range. Choice D (Casual blood glucose 90 mg/dL) is within the normal range and does not indicate impaired glucose tolerance.

4. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

• A. Amount of food and fluid taken during the last meal before treatment
• B. Respiratory rate, breath sounds, and location of congestion
• C. Teaching the client's relatives to perform the procedure
• D. Doctor's order regarding position restrictions and client's tolerance for lying flat

Correct answer: B

Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.

5. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

• A. Self-esteem disturbance
• B. Impaired urinary elimination
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

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