When taking a blood pressure reading, where should the cuff be positioned?
- A. The cuff should be deflated fully before immediately starting a second reading for the same patient
- B. The cuff should be deflated quickly after being inflated to 180 mmHg
- C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
- D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery
Correct Answer: D
Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.
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What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?
- A. Mrs. Guevarra makes the assignment to instruct the staff member
- B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
- C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
- D. Mrs. Guevarra must know how to perform the task being delegated
Correct Answer: C
Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.
A nurse is providing preventative information to a group of parents with toddlers about choking. Which food item should the nurse recommend for this age group?
- A. Banana slices
- B. Popcorn
- C. Hot dogs
- D. Carrot sticks
Correct Answer: A
Rationale: Banana slices are the most suitable food option for toddlers to prevent choking. Toddlers are at a higher risk of choking due to their small airways and developing chewing abilities. Banana slices are soft, easy to chew, and less likely to cause choking compared to other options. Popcorn and hot dogs are common choking hazards for young children due to their shape and texture. While carrot sticks may be a healthy choice, they can also pose a choking risk due to their hardness and shape. Therefore, recommending banana slices to parents of toddlers is the safest choice to prevent choking incidents, making choice 'A' the correct answer. Choices 'B', 'C', and 'D' are incorrect because they can potentially cause choking in toddlers.
Which food items should be consumed with nonheme iron to increase its absorption, according to a nurse's education plan for clients?
- A. Kiwi
- B. Strawberries
- C. Coffee
- D. Kiwi and Strawberries
Correct Answer: D
Rationale: The correct answer is D: Kiwi and Strawberries. Both of these fruits are high in vitamin C, a nutrient known to enhance the absorption of nonheme iron. Vitamin C facilitates the conversion of nonheme iron into a form that is more readily absorbed by the body, thereby enhancing iron intake. In contrast, coffee (Choice C) contains certain compounds that can actually inhibit the absorption of iron, making it a less desirable choice when the goal is to increase iron absorption. Consequently, Choices A (Kiwi), B (Strawberries), and C (Coffee) were specifically picked to highlight the varying effects of different food items on nonheme iron absorption.
Which of the following is reflected in an ECG due to hypokalemia?
- A. Tall T waves and Pathologic Q wave
- B. Widening QRS Complex and U wave
- C. None of the above
- D. Both A and B
Correct Answer: B
Rationale: Hypokalemia, a condition characterized by low levels of potassium in the blood, is reflected in an ECG by a widening QRS Complex and a U wave. This is because potassium plays a key role in the electrical activity of the heart, and its deficiency can lead to abnormalities in the heart's rhythm as represented by these specific changes on the ECG. Choice A is incorrect as tall T waves and pathologic Q waves are more commonly associated with hyperkalemia or myocardial infarction, respectively, rather than hypokalemia. Choices C and D are also incorrect as they do not accurately reflect the ECG changes caused by hypokalemia.
What characterizes Obsessive Compulsive Disorder?
- A. Uncontrollable impulse to perform an act or ritual repeatedly
- B. Persistent thoughts and behavior
- C. Recurring unwanted and disturbing thoughts
- D. Pathological persistence of unwilled thoughts
Correct Answer: A
Rationale: Obsessive Compulsive Disorder (OCD) is characterized by the uncontrollable impulse to perform an act or ritual repeatedly (Choice A). This is driven by recurring unwanted and disturbing thoughts (Choice C), but the distinguishing factor is the compulsive behavior, making choice A the most accurate. While choice B can be seen as true, it lacks the specific detail of the compulsive behavior that makes A a better answer. Choice D is not incorrect, but it uses terminology that is less precise and less commonly used to describe OCD, making it a less accurate choice than A. The provided rationale is not relevant to the question.