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. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:

• A. Set and turn on the alarm of the oximeter
• B. Do nothing since there is no identified problem
• C. Cover the fingertip sensor with a towel or bedsheet
• D. Change the location of the sensor every four hours

Correct answer: B

Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.

3. What intervention would be most appropriate for a patient who has difficulty eating because of chewing problems?

• A. Use squeeze bottles to pour liquids into the mouth
• B. Provide utensils that have modified handles
• C. Offer plates with food guards
• D. Provide soft foods

Correct answer: D

Rationale: Providing soft foods is crucial for patients with chewing difficulties to ensure they can consume adequate nutrition without discomfort.

4. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?

• A. Stay with the client for the first 15 minutes of blood administration
• B. Stay with the client for the entire period of blood administration
• C. Run the infusion at a faster rate during the first 15 minutes
• D. Inform the client to notify the staff immediately for any adverse reaction

Correct answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

5. Which set of guidelines is intended to assess nutrient adequacy or plan intakes of population groups, not individuals?

• A. Old Recommended Dietary Allowances (RDA)
• B. Estimated Average Requirement (EAR)
• C. New Recommended Dietary Allowances (RDA)
• D. Tolerable Upper Intake Level (UL)

Correct answer: B

Rationale: The Estimated Average Requirement (EAR) is specifically designed to assess nutrient adequacy or plan intakes for population groups, not for individuals. The Old and New Recommended Dietary Allowances (RDA) are meant for individuals, not groups, as they provide guidelines for specific nutrient intake levels for healthy individuals. The Tolerable Upper Intake Level (UL) is used to set the highest level of nutrient intake that is likely to pose no risk of adverse health effects for most individuals in a group, which is different from assessing nutrient adequacy for groups.

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