Question

The nurse is preparing to assess the blood pressure of a 3-year- old. How should the nurse proceed?

Answer 1

Correct Answers:

Explain the procedure to the child.

Rationale :

📌When caring for pediatric clients, especially toddlers and preschoolers, effective communication is key to reducing anxiety and promoting cooperation.

📌Explaining the procedure in a developmentally appropriate manner helps the child understand what to expect, reducing fear and increasing trust.

📌It also minimizes resistance and ensures a more accurate blood pressure reading by promoting cooperation and calming the child.

📌Building rapport through explanation supports child-centered care and fosters a therapeutic nurse-client relationship.

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Answer 2

Correct Answers:

Angiotensin-converting enzymes (ACE) inhibitors

Rationale :

✍ACE inhibitors (e.g., lisinopril, enalapril) can cause a persistent, dry, nonproductive cough in some patients.

✍This side effect results from the accumulation of bradykinin, a peptide that stimulates cough receptors in the lungs.

✍This is a well-documented and bothersome adverse effect that often necessitates switching the patient to an angiotensin II receptor blocker (ARB), which doesn't cause bradykinin accumulation.

✍The nurse must be aware of this to advocate for appropriate medication changes.

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Answer 3

Correct Answers:

Aortic and Pulmonic

Rationale :

♦The S2 heart sound is created by the closure of the semilunar valves—the aortic and pulmonic valves—at the end of systole, marking the beginning of diastole.

♦This sound is best heard at the base of the heart (2nd intercostal space).

♦Accurate auscultation of this sound helps the nurse assess cardiac cycle integrity and detect abnormal valvular function.

♦Recognizing heart sounds is critical for identifying murmurs or stenosis.

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Answer 4

Correct Answers:

Consider what is important in any given situation.

Rationale :

💎Critical thinking involves analyzing patient-specific data, prioritizing problems, and applying nursing judgment to make the most appropriate decisions.

💎It is not rigid or routine-based.

💎The nurse must evaluate each clinical scenario to determine what is most significant.

💎This individualized approach improves patient outcomes, ensures safe care, and reflects professional reasoning.

💎Following orders blindly or relying on intuition alone does not constitute critical thinking.

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Answer 5

Correct Answers:

Assess the apical pulse for a full minute.

Rationale :

🎯An irregular radial pulse suggests a cardiac arrhythmia, making the apical pulse assessment essential.

🎯The apical pulse, heard at the fifth intercostal space at the midclavicular line, gives the most accurate reflection of cardiac rhythm and rate.

🎯Measuring for a full 60 seconds ensures that variations in beat strength or timing are captured.

🎯This step is crucial for diagnosing atrial fibrillation or other dysrhythmias.

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Answer 6

Correct Answers:

You will need to recalibrate the machine

Rationale :

⚫Portable electronic blood pressure monitors must be regularly recalibrated to maintain accuracy, especially when used at home for long-term hypertension monitoring.

⚫Recalibration ensures that readings reflect true blood pressure levels and help avoid undertreatment or overtreatment.

⚫The nurse must educate the patient about proper device maintenance and how to follow the manufacturer’s instructions regarding recalibration intervals.

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Answer 7

Correct Answers:

Sedation

Rationale :

⏺Diphenhydramine, a first-generation antihistamine, crosses the blood-brain barrier and can cause CNS depression, leading to drowsiness or sedation.

⏺This is a common adverse effect and must be communicated to patients, especially if they operate machinery, drive, or are elderly (due to fall risk).

⏺Patient education about avoiding alcohol and CNS depressants is also necessary.

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Answer 8

Correct Answers:

Apply 4 to 5 mL of liquid soap to the hands.

Rationale :

🔴Proper hand hygiene is a fundamental infection control practice.

🔴Applying 4 to 5 mL of liquid soap provides adequate lather to cover all surfaces of the hands, ensuring effective removal of pathogens, organic matter, and contaminants.

🔴This step must be followed by vigorous rubbing for at least 20 seconds, rinsing with water, and drying with a clean towel.

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Answer 9

Correct Answers:

Pulse oximetry assessment

Rationale :

💥Oxygenation status, measured by pulse oximetry, is essential in determining tissue perfusion, which directly impacts wound healing.

💥Adequate oxygen levels support collagen formation, angiogenesis, and immune cell activity needed for effective wound repair.

💥Hypoxia impairs fibroblast function and slows tissue regeneration.

💥Thus, SpO₂ is a crucial assessment parameter for any patient with wounds.

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Answer 10

Correct Answers:

Decrease level of consciousness

Rationale :

◾A decreased level of consciousness (LOC) is a major predisposing factor for pressure ulcer development because the client is unable to recognize or communicate discomfort, pain, or the need to change position.

◾This leads to prolonged pressure on bony prominences, impaired circulation, and tissue breakdown.

◾Clients with altered LOC require frequent repositioning and focused skin assessments to prevent ulcers.

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RN Fundamentals Exam Special~ADN

No.

1 : The nurse is preparing to assess the blood pressure of a 3-year- old. How should the nurse proceed?

2 : A patient who has been taking antihypertensive drugs for a few months states that a new, persistent dry cough is very bothersome. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs?

3 : A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?

4 : Which action should the nurse take when using critical thinking to make clinical decisions?

5 : A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

7 : A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication?

8 : A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

9 : A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?

10 : A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?

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