How many cc are there in 25 ounces?

Patients who cannot move in their bed on their own should be turned at least ________________.

A. once a day
B. twice a day
C. every 2 hours
D. every 4 hours

Correct Answer: C

Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.

A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?

A. Allow 5 minutes for the student to relax and rest before checking their vital signs.
B. Check the blood pressure in both arms, expecting a difference in the readings due to the recent exercise.
C. Immediately monitor the student's vital signs upon arrival at the clinic and then 5 minutes later, recording any differences.
D. Check the student's blood pressure in the supine position to provide a more accurate reading and allow the student to relax at the same time.

Correct Answer: A

Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.

What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?

A. The popliteal artery should be auscultated to obtain thigh pressure.
B. The best position to measure thigh pressure is the prone position.
C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.

Correct Answer: C

Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?

A. Respirations should be counted for 1 full minute.
B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.

Correct Answer: A

Rationale: To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.

Why should a palpated pressure be performed before auscultating blood pressure?

A. To more clearly hear the Korotkoff sounds.
B. To detect the presence of an auscultatory gap.
C. To avoid missing a falsely elevated blood pressure.
D. To more readily identify phase IV of the Korotkoff sounds.

Correct Answer: B

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.

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