Nokea
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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A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
- A. Perform mental health assessment interviews
- B. Establish therapeutic relationships
- C. Prescribe psychotropic medications
- D. Individualize nursing care plans
Correct Answer: C
Rationale: Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. In this scenario, the new staff nurse would ask the advanced practice nurse to prescribe psychotropic medications, as this is within their scope of practice and expertise. Establishing therapeutic relationships, performing mental health assessments, and individualizing care plans are typically responsibilities of staff nurses at the basic level, not advanced practice nurses.
You have measured the urinary output of your resident at the end of your 8-hour shift. The output is 25 ounces. What should you do next?
- A. Convert the number of ounces into cc.
- B. Convert the number of ounces into cm.
- C. Immediately report this poor output to the nurse.
- D. Know that 25 ounces of urine is too much in 8 hours.
Correct Answer: A
Rationale: You should convert the number of ounces into cc because cc is the unit of measurement used to record intake and output accurately. This urinary output falls within normal limits, so there is no need to report it immediately to the nurse. It is essential to report urinary outputs of less than 30 cc per hour to detect potential issues early. Converting ounces into centimeters (cm) is not appropriate in this context as cm is a unit of length, not volume. Knowing that 25 ounces of urine is too much in 8 hours is inaccurate as it depends on various factors like fluid intake and individual differences.
What technique would the nurse use to accurately assess a rectal temperature in an adult?
- A. Use a lubricated blunt tip thermometer.
- B. Insert the thermometer 2 to 3 inches into the rectum.
- C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
- D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Correct Answer: A
Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?
- A. 240 cc
- B. 120 cc
- C. 8 cc
- D. 0 cc because Italian ice is not a fluid
Correct Answer: A
Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.
A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?
- A. A history of hepatitis C five years previously
- B. Cholecystitis requiring cholecystectomy one year previously
- C. Asymptomatic diverticulosis
- D. Crohn's disease in remission
Correct Answer: A
Rationale: A history of hepatitis C five years previously would prevent a donor from donating blood for transfusion. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis requiring cholecystectomy one year previously, asymptomatic diverticulosis, and Crohn's disease in remission are not contraindications for blood donation as they do not pose a risk of transmitting infections to the recipient.