The nurse observes a UAP taking a client's blood pressure in the
lower extremity. Which observation of this procedure requires the
nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower
leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure
in the client's arm. - <<<<ANSWERS>>>B
Rationale: When obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for auscultation when
the blood pressure cuff is applied around the thigh. The nurse
should intervene with the UAP who has applied the cuff on the
lower leg. Option A ensures an accurate assessment, and option
C provides the best access to the artery. Systolic pressure in the
popliteal artery is usually 10 to 40 mm Hg higher than in the
brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the
nurse that her child is often awake until midnight playing and is
,then very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the
mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is
experiencing
D.
Description of the family's home environment -
<<<<ANSWERS>>>D
Rationale: School-age children often resist bedtime. The nurse
should begin by assessing the environment of the home to
determine factors that may not be conducive to the establishment
of bedtime rituals that promote sleep. Option A often causes
daytime fatigue rather than resistance to going to sleep. Option B
is unlikely to provide useful data. The nurse cannot determine
option C.
The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree) burns.
What action has the highest priority in decreasing the client's risk
of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns - <<<<ANSWERS>>>B
Rationale: Careful handwashing technique is the single most
effective intervention for the prevention of contamination to all
,clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the
proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to
prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration
and finds that the peripheral IV rate by gravity has slowed, even
though the venous access site is healthy. What should the nurse
do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. -
<<<<ANSWERS>>>B
Rationale: The nurse should first check the tubing and height of
the bag on the IV pole, which are common factors that may slow
the rate. Gravity infusion rates are influenced by the height of the
bag, tubing clamp closure or kinks, needle size or position, fluid
viscosity, client blood pressure (crying in the pediatric client), and
infiltration. Venospasm can slow the rate and often responds to
warmth over the vessel, but the nurse should first adjust the IV
pole height. The nurse may need to adjust the stabilizing tape on
a positional needle or flush the venous access with normal saline,
but less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Which action should be included in this instruction?
A.
, Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. -
<<<<ANSWERS>>>A
Rationale: Performing range-of-motion exercises is beneficial in
reducing contractures around joints. Options B, C, and D are all
potentially harmful practices that place the immobile client at risk
of complications.
The nurse is called to the waiting room of a pediatric clinic. The
frantic mother states, "I think my 4-month-old baby is choking!"
What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. - <<<<ANSWERS>>>B, C, D
Rationale: The fingers are placed at the same location on an
infant as chest compressions for CPR; however, the nurse must
deliver five chest thrusts, after the five back slaps. Blind sweeps
are not used as this action may push the object deeper into the
throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed
blood transfusion?
lower extremity. Which observation of this procedure requires the
nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower
leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure
in the client's arm. - <<<<ANSWERS>>>B
Rationale: When obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for auscultation when
the blood pressure cuff is applied around the thigh. The nurse
should intervene with the UAP who has applied the cuff on the
lower leg. Option A ensures an accurate assessment, and option
C provides the best access to the artery. Systolic pressure in the
popliteal artery is usually 10 to 40 mm Hg higher than in the
brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the
nurse that her child is often awake until midnight playing and is
,then very difficult to awaken in the morning for school. Which
assessment data should the nurse obtain in response to the
mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is
experiencing
D.
Description of the family's home environment -
<<<<ANSWERS>>>D
Rationale: School-age children often resist bedtime. The nurse
should begin by assessing the environment of the home to
determine factors that may not be conducive to the establishment
of bedtime rituals that promote sleep. Option A often causes
daytime fatigue rather than resistance to going to sleep. Option B
is unlikely to provide useful data. The nurse cannot determine
option C.
The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree) burns.
What action has the highest priority in decreasing the client's risk
of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns - <<<<ANSWERS>>>B
Rationale: Careful handwashing technique is the single most
effective intervention for the prevention of contamination to all
,clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the
proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to
prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration
and finds that the peripheral IV rate by gravity has slowed, even
though the venous access site is healthy. What should the nurse
do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. -
<<<<ANSWERS>>>B
Rationale: The nurse should first check the tubing and height of
the bag on the IV pole, which are common factors that may slow
the rate. Gravity infusion rates are influenced by the height of the
bag, tubing clamp closure or kinks, needle size or position, fluid
viscosity, client blood pressure (crying in the pediatric client), and
infiltration. Venospasm can slow the rate and often responds to
warmth over the vessel, but the nurse should first adjust the IV
pole height. The nurse may need to adjust the stabilizing tape on
a positional needle or flush the venous access with normal saline,
but less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Which action should be included in this instruction?
A.
, Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. -
<<<<ANSWERS>>>A
Rationale: Performing range-of-motion exercises is beneficial in
reducing contractures around joints. Options B, C, and D are all
potentially harmful practices that place the immobile client at risk
of complications.
The nurse is called to the waiting room of a pediatric clinic. The
frantic mother states, "I think my 4-month-old baby is choking!"
What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. - <<<<ANSWERS>>>B, C, D
Rationale: The fingers are placed at the same location on an
infant as chest compressions for CPR; however, the nurse must
deliver five chest thrusts, after the five back slaps. Blind sweeps
are not used as this action may push the object deeper into the
throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed
blood transfusion?
