Nursing Elites

1. What is the proper technique for measuring a patient's blood pressure?

• A. Place the cuff at heart level and listen for Korotkoff sounds
• B. Ensure the patient is in a seated position and inflate the cuff to 180 mmHg
• C. Use a manual sphygmomanometer and measure blood pressure on both arms
• D. Monitor pulse rate and apply pressure to the brachial artery

Correct answer: A

Rationale: The correct technique for measuring blood pressure involves placing the cuff at heart level to ensure accurate readings. Listening for Korotkoff sounds helps determine the systolic and diastolic pressures. Choice B is incorrect as inflating the cuff to 180 mmHg is excessive and can lead to inaccurate readings. Choice C is incorrect as it is unnecessary to measure blood pressure on both arms unless there is a specific medical reason to do so. Choice D is incorrect as monitoring pulse rate and applying pressure to the brachial artery are not part of the standard blood pressure measurement technique.

2. A nurse is receiving report on four clients. Which of the following clients should the nurse plan to see first?

• A. A client who is NPO and has dry mucous membranes
• B. A client with rotavirus who has been vomiting
• C. A client who has a urinary catheter and cloudy urine
• D. A client who has pneumonia and a new onset of confusion

Correct answer: D

Rationale: The correct answer is D because a client with pneumonia and a new onset of confusion needs immediate evaluation for changes in neurological status. This could indicate a decline in respiratory status or potential complications such as hypoxia or sepsis. Option A, a client who is NPO and has dry mucous membranes, may need intervention but does not indicate an acute change in condition. Option B, a client with rotavirus who has been vomiting, requires assessment and intervention but does not pose an immediate threat to life. Option C, a client with a urinary catheter and cloudy urine, may indicate a urinary tract infection but does not require immediate attention compared to the client with new onset confusion and pneumonia.

3. A nurse is providing discharge instructions for a client with diabetes. What is the most important teaching point?

• A. Monitor blood sugar levels weekly
• B. Administer insulin before meals as prescribed
• C. Take medication only when feeling unwell
• D. Monitor blood sugar only in the morning

Correct answer: B

Rationale: The correct answer is B: Administer insulin before meals as prescribed. This is the most important teaching point because insulin administration before meals helps manage blood sugar effectively in diabetic patients. Choice A is incorrect because monitoring blood sugar levels weekly may not provide timely information for managing diabetes. Choice C is incorrect as medications for diabetes should be taken as prescribed, not only when feeling unwell. Choice D is incorrect as blood sugar levels should be monitored at various times throughout the day, not just in the morning, to get a complete picture of the patient's condition.

4. A client with heart failure is receiving furosemide. Which of the following assessment findings indicates that the medication is effective?

• A. Elevated blood pressure.
• B. Absence of adventitious breath sounds.
• C. Weight gain of 1.4 kg (3 lb) in 24 hr.
• D. Decreased urine output.

Correct answer: B

Rationale: The absence of adventitious breath sounds indicates that furosemide is effective in managing heart failure. Adventitious breath sounds such as crackles indicate fluid accumulation in the lungs, a common complication of heart failure. Therefore, the absence of these abnormal sounds suggests that furosemide is effectively reducing fluid overload. Elevated blood pressure (choice A) is not a desired outcome in heart failure management. Weight gain (choice C) and decreased urine output (choice D) are signs of fluid retention and ineffective diuresis, indicating that furosemide is not working effectively.

5. A client is learning to use a cane. What instruction is essential for this client?

• A. Advance the cane and the weaker leg at the same time
• B. Maintain two points of support on the ground at all times
• C. Use the cane on the weaker side for better support
• D. Advance the cane 30 to 45 cm with each step

Correct answer: B

Rationale: The correct instruction for a client learning to use a cane is to maintain two points of support on the ground at all times. This ensures better stability and reduces the risk of falls. Choice A is incorrect because advancing the cane and the weaker leg simultaneously may lead to imbalance. Choice C is incorrect because the cane should be used on the stronger side to provide support. Choice D is incorrect because there is no specific measurement for advancing the cane with each step, and the focus should be on maintaining stability.

Similar Questions