Nokea
Which of the following is a true statement about assessing blood pressure by palpation?
- A. Only the diastolic blood pressure can be assessed through palpation.
- B. The palpation technique is most useful for infants and small children.
- C. Hypertension is a common condition that might need to be assessed through blood pressure palpation.
- D. Only the systolic blood pressure can be assessed through palpation.
Correct Answer: D
Rationale: When assessing blood pressure by palpation, it is important to note that only the systolic blood pressure can be determined accurately using this method. Diastolic blood pressure cannot be reliably assessed through palpation. The palpation technique is particularly useful in situations where traditional blood pressure measurement methods are challenging, such as in infants, small children, or individuals with low blood pressure that is difficult to hear. Hypertension, a common condition characterized by elevated blood pressure, is typically assessed using auscultation rather than palpation. Therefore, the correct statement is that only the systolic blood pressure can be assessed through palpation.
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The nurse is teaching a client the proper technique for using a cane. Which statements should the nurse include in the teaching? Select all that apply.
- A. Hold the cane on the affected side.
- B. Hold the cane on the unaffected side.
- C. Move the cane at the same time as the affected leg.
- D. Move the cane at the same time as the unaffected leg.
- E. Hold the cane 8 to 10 inches from the side of the foot.
Correct Answer: B,C
Rationale: The cane is held on the unaffected side and moved with the affected leg to provide support. The cane is held closer to the body, not 8-10 inches away.
A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct Answer: D
Rationale: An amniocentesis is performed to draw amniotic luid from the sac around the fetus during pregnancy. It may be analyzed for certain disorders or complications associated with pregnancy. Following the procedure, the nurse should wash the client's abdomen and place a small bandage over the puncture site
Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?
- A. The test determines if the client is anemic and needs iron supplements
- B. The test determines if there is excess glucose building up in the urine
- C. The test determines the amount of hemoglobin reaching the liver to support gluconeogenesis
- D. The test determines the amount of hemoglobin that is coated with glucose
Correct Answer: D
Rationale: A hemoglobin A1C test, also known as a glycated hemoglobin test, determines the amount of hemoglobin that is coated with glucose. Excess glucose in the bloodstream may cause it to attach to hemoglobin on red blood cells. Because the life of these cells is between 2 and 3 months, the hemoglobin A1C is an accurate measurement of a client's glucose during that time. Choices A, B, and C are incorrect. Choice A relates to anemia and iron supplements, which are not assessed by a hemoglobin A1C test. Choice B mentions excess glucose in the urine, which is typically assessed through a urine glucose test, not the hemoglobin A1C test. Choice C is incorrect as the test is not related to the amount of hemoglobin reaching the liver to support gluconeogenesis; instead, it specifically measures the amount of hemoglobin that is glycated or coated with glucose.
A healthcare professional is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:
- A. Disconnect the current infusion
- B. Clean the cap with alcohol and attach a 5 cc syringe
- C. Draw 5 cc of a blood sample to discard
- D. Flush with saline after the sample
Correct Answer: B
Rationale: When drawing a blood specimen from a central line, the healthcare professional should disconnect any infusions that are currently running and that could contaminate the specimen. It is important to use a minimum size of a 10 cc syringe when using a central line to avoid placing too much pressure on the catheter. Cleaning the cap with alcohol and attaching a 5 cc syringe is not appropriate as a larger syringe size should be used for this procedure. Drawing 5 cc of a blood sample to discard and flushing with saline after the sample are correct steps in the process of drawing a blood specimen from a central line.
What factors should the nurse consider for teaching a child about his or her disease and related health care measures?
- A. A child rarely forms misconceptions.
- B. The older the child, the shorter the attention span.
- C. A child's imagination may create greater fear than the truth.
- D. A child may regress developmentally in a situation of illness.
- E. It is not necessary to assess the child's knowledge before teaching.
- F. A child may better manage uncomfortable information through role-playing.
Correct Answer: C,D,F
Rationale: For children, the teaching-learning process may be fundamentally different from that used for adults, and the nurse needs to adjust the complexity and volume of information based on the child's age and cognitive level. The factors that need to be addressed when teaching children include the following: Trust is essential to a therapeutic relationship; in general, the younger the child, the shorter the attention span; assessing the child's knowledge is important because children are exposed to various levels of information about health care; children form misconceptions easily, and a child's imagination may create greater fear than the truth; a child may regress developmentally in a situation of illness; and a child may better manage uncomfortable information through role-playing.