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 offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Beneficence

Correct answer: D

Rationale: In this scenario, offering pain medication to a postoperative client before ambulation is an example of beneficence. Beneficence is the ethical principle related to promoting the well-being of the client, which includes providing pain relief to improve the client's comfort and facilitate their recovery. Fidelity (choice A) is about honoring commitments and being faithful to agreements, not directly related to pain management. Autonomy (choice B) refers to respecting the client's right to make decisions about their care, not specifically about pain medication administration. Justice (choice C) involves fairness and equality in healthcare resource allocation, not directly applicable in this situation.

3. A nurse is preparing a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?

• A. Hgb 12.8 g/dl.
• B. Potassium 4.2 mEq/L.
• C. RBC 4.4 million/mm3.
• D. Platelets 100,000/mm3.

Correct answer: D

Rationale: The correct answer is D: "Platelets 100,000/mm3." A platelet count of 100,000/mm3 is low and increases the client's risk for bleeding, which is crucial information to communicate during the change-of-shift report. Choices A, B, and C provide values within normal ranges and are not directly related to the client's postoperative status or risk for complications. Therefore, they are not the priority information to include in the report.

4. What intervention is essential for a client with dehydration?

• A. Monitor electrolyte levels regularly
• B. Administer oral rehydration solutions
• C. Increase fluid intake to maintain hydration
• D. Administer intravenous fluids to treat dehydration

Correct answer: B

Rationale: Administering oral rehydration solutions is essential for a client with dehydration as it helps replenish lost fluids and electrolytes directly through the oral route. Monitoring electrolyte levels regularly (Choice A) is important but not as essential as providing immediate rehydration. Increasing fluid intake to maintain hydration (Choice C) may not be sufficient for a client already dehydrated and needing rapid replenishment. Administering intravenous fluids (Choice D) is a more invasive intervention typically reserved for severe cases of dehydration or when the client cannot tolerate oral fluids.

5. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?

• A. Client reports nausea.
• B. Urinary output of 20 mL/hr.
• C. Oxygen saturation 90%.
• D. Respiratory rate 14/min.

Correct answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.

Similar Questions