Nursing Elites

1. What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?

• A. Diastolic blood pressure may not be heard.
• B. Diastolic blood pressure may be falsely low.
• C. Systolic blood pressure may be falsely low.
• D. Systolic blood pressure may be falsely high.

Correct answer: C

Rationale: If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.

2. What is the most important step that healthcare personnel can take to prevent the transmission of microorganisms in the hospital setting?

• A. Wear protective eyewear at all times.
• B. Wear gloves whenever in direct contact with patients.
• C. Wash hands before and after contact with each patient.
• D. Clean the stethoscope with an alcohol swab between patients.

Correct answer: C

Rationale: The most crucial step in preventing the transmission of microorganisms in the hospital setting is proper hand hygiene. Healthcare personnel should wash their hands thoroughly before and after each patient contact to reduce the risk of spreading infections. While cleaning the stethoscope with an alcohol swab between patients is recommended, it is secondary to hand hygiene. Wearing protective eyewear at all times is not necessary for routine patient care unless specifically indicated, and wearing gloves only when in direct contact with patients is important but not as critical as proper handwashing. Therefore, the correct answer is to wash hands before and after contact with each patient.

3. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?

• A. The nurse ties the restraints in a square knot to prevent the client from untying them
• B. The restraints are attached to a movable portion of the bed
• C. The padded side of the restraint is applied next to the skin of the wrist
• D. The nurse assesses the client's distal circulation every 24 hours

Correct answer: C

Rationale: Restraint use must prioritize the safety of the client. When applying restraints around the wrists, the padded side should be placed against the skin to help prevent skin breakdown. Additionally, restraints should be secured in quick-release knots to ensure they can be removed rapidly in case of an emergency. Choice A is incorrect as restraints should not be tied in a way that could prevent quick removal. Choice B is incorrect because restraints should not be attached to a movable part of the bed to avoid unintentional movement. Choice D is incorrect as assessing distal circulation is important but is not directly related to the safe application of restraints.

4. An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?

• A. Take off shoes while in the house and wear only socks
• B. Limit activities to the lower level of the home
• C. Keep a lamp near the door of every room
• D. Install non-slip pads in the shower or bathtub

Correct answer: D

Rationale: To reduce the risk of falling at home for an elderly client with decreased visual acuity and using a cane for mobility, installing non-slip pads in the shower or bathtub is crucial. This measure helps prevent slips and falls in areas where water accumulation may occur. While taking off shoes and wearing socks may seem comfortable, it increases the risk of slipping. Limiting activities to the lower level of the home may restrict the client's independence and quality of life unnecessarily. Keeping a lamp near the door of every room may improve visibility but does not directly address the risk of falls associated with mobility and visual acuity issues.

5. The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?

• A. Onset of labor in a pregnant woman
• B. Stroke
• C. Heart attack
• D. Migraine

Correct answer: B

Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care. Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.

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