Nursing Elites

1. While measuring a patient's blood pressure, which factor influences a patient's blood pressure?

• A. Pulse rate
• B. Pulse pressure
• C. Vascular output
• D. Peripheral vascular resistance

Correct answer: D

Rationale: When measuring a patient's blood pressure, it is important to consider various factors that influence blood pressure. Peripheral vascular resistance plays a crucial role in regulating blood pressure. The level of blood pressure is affected by factors such as cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. Pulse rate (Choice A) refers to the number of heartbeats per minute and is not a primary factor influencing blood pressure. Pulse pressure (Choice B) is the difference between systolic and diastolic blood pressure and does not directly impact blood pressure regulation. Vascular output (Choice C) is not a recognized term in blood pressure regulation and is not a primary factor affecting blood pressure.

2. The Sinoatrial Node (SA) is located within which of the following heart structures?

• A. Mitral Valve
• B. Right Ventricle
• C. Right Atrium
• D. Left Atrium

Correct answer: C

Rationale: The Sinoatrial (SA) Node, often called the heart's natural pacemaker, is situated within the upper wall of the Right Atrium. It initiates the electrical impulses that regulate the heartbeat. Choices A, B, and D are incorrect because the SA node is not located in the Mitral Valve, Right Ventricle, or Left Atrium. It is specifically positioned in the Right Atrium to coordinate the heart's rhythm and timing.

3. The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should:

• A. Formulate post-discharge nursing diagnoses
• B. Draw conclusion about resolution of current client problems
• C. Assess the client for baseline data to be used at the LTC facility
• D. Plan the care that is needed in the LTC facility

Correct answer: B

Rationale: To effectively communicate the client's outcome goals that were met and those that were not to the LTC staff, the nurse should draw conclusions about the resolution of the current client problems. Terminal evaluation is performed to determine the client's condition at discharge, focusing on which goals were achieved and which were not. Formulating post-discharge nursing diagnoses (option A) is not the most appropriate action in this scenario as it focuses on identifying potential problems after discharge rather than evaluating achieved goals. Assessing the client for baseline data (option C) is not necessary at this point as the focus is on evaluating outcomes rather than collecting baseline data. Planning the care needed in the LTC facility (option D) is premature as this should be done on admission to the LTC facility and not during the discharge process.

4. You have been assigned to take an apical pulse for one of the patients on the nursing unit. How will you do this?

• A. You will place the stethoscope over the heart and listen for any irregular beats.
• B. You will place the stethoscope over the heart and count the beats per minute.
• C. You will place your fingertip over the patient's wrist and feel for any irregular beats.
• D. You will place your fingertip over the patient's wrist and count the beats per minute.

Correct answer: B

Rationale: To take an apical pulse accurately, you should place the stethoscope over the heart and count the number of beats per minute. This method provides a precise assessment of the heart rate. While listening for irregular beats is essential for assessing the heart's rhythm, the primary objective of taking an apical pulse is to determine the heart rate. Choices C and D are incorrect because the apical pulse is not taken at the wrist; instead, it is obtained by auscultating at the apex of the heart, usually at the point where the fifth intercostal space meets the midclavicular line.

5. Digestion, elimination, and ___________ are the three functions of the digestive system.

• A. constriction
• B. relaxation
• C. absorption
• D. peristalsis

Correct answer: C

Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.

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