Nursing Elites

1. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT:

• A. Take the blood pressure reading on both arms for comparison
• B. Listen to and identify the phases of Korotkoff sounds
• C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
• D. Observe procedures for infection control

Correct answer: B

Rationale: When measuring blood pressure, it is crucial to follow specific steps to obtain accurate readings. Taking the blood pressure on both arms for comparison helps assess any variations. Pumping the cuff to around 50 mmHg above the point of pulse obliteration ensures accurate measurements. Observing procedures for infection control is vital to prevent the spread of infections. Listening to and identifying the phases of Korotkoff sounds are associated with auscultatory blood pressure measurements, not the initial blood pressure reading process.

2. Membership dropout generally occurs in group therapy after a member:

• A. Accomplishes his goal in joining the group
• B. Discovers that his feelings are shared by the group members
• C. Experiences feelings of frustration in the group
• D. Discusses personal concerns with group members

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

3. What is a likely effect on a patient whose lab results reveal hypoalbuminemia?

• A. Infection
• B. Rickets
• C. Hypertension
• D. Edema

Correct answer: D

Rationale: Hypoalbuminemia, which refers to low albumin levels in the blood, is often associated with edema. Albumin helps maintain oncotic pressure, which keeps fluid within blood vessels. When albumin levels are low, this pressure decreases, leading to fluid leakage from the blood vessels into the surrounding tissues, resulting in edema. The other choices are less likely effects of hypoalbuminemia. Hypoalbuminemia doesn't directly cause infections (Choice A), rickets (Choice B) caused by vitamin D deficiency, or hypertension (Choice C) associated with factors like high sodium intake, obesity, and genetic predisposition.

4. In monitoring the patient in PACU, the nurse correctly identifies that checking the patient's vital signs is done every:

• A. 1 hour
• B. 5 minutes
• C. 15 minutes
• D. 30 minutes

Correct answer: A

Rationale: Correct Answer: A - Vital signs monitoring in the PACU (Post-Anesthesia Care Unit) is typically done every hour to closely monitor the patient's condition during the immediate postoperative period. This frequency allows the nurse to promptly identify any changes in the patient's vital signs and intervene as necessary. Choice B (5 minutes) is too frequent for routine vital signs monitoring in the PACU and may not allow for a comprehensive assessment of the patient's stability. Choice C (15 minutes) and Choice D (30 minutes) are also not in line with the standard practice of vital signs monitoring in the PACU, which is typically hourly.

5. During the first 24 hours after the thermal injury, you should assess Sergio for:

• A. hypokalemia and hypernatremia
• B. hypokalemia and hyponatremia
• C. hyperkalemia and hyponatremia
• D. hyperkalemia and hypernatremia

Correct answer: D

Rationale: During the initial phase after a thermal injury, the major concern is the release of potassium due to cell damage, leading to hyperkalemia. Hypernatremia is not typically a primary concern in the immediate post-injury phase. Hyponatremia is less likely to occur initially after a burn injury. Therefore, the correct assessment for Sergio during the first 24 hours after the thermal injury would be hyperkalemia and hypernatremia.

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