NR-224 Fundamentals – Skills - Set 3 - Part 3

Correct Answer: Sit upright and lean forward on a table

Sitting upright and leaning forward on an overbed table is the orthopneic position. It drops the diaphragm, lets the abdominal contents fall away from the chest and gives the accessory muscles a fixed base. Option a is incorrect because any recumbent position lets abdominal organs press upward against the diaphragm. Side-lying with bent knees relieves abdominal wall tension, which is a comfort measure and not a breathing one. Option b is incorrect because shallow breaths move less air into the alveoli and worsen the very problem the client feels. Pursed-lip breathing with a slow full exhalation is what relieves air trapping. Option c is incorrect because lowering the head of the bed moves the client toward flat, the exact position that triggered the breathlessness. Lung expansion shrinks as the trunk goes down.

Correct Answer: Begin rapid cooling and activate emergency services

Hot dry skin with altered mental status is heat stroke, a failure of thermoregulation with high mortality. Organ damage tracks the time spent at extreme temperature, so cooling starts at once alongside the emergency call. Option a is incorrect because oral fluids are unsafe for anyone whose mental status is altered, since the airway is no longer protected. Rehydration matters in heat exhaustion, where the client stays alert and oriented. Option b is incorrect because antipyretics lower a set point that pyrogens have raised. In heat stroke the set point is normal and the problem is trapped heat, so the drug accomplishes nothing while time passes. Option d is incorrect because shade alone will not pull core temperature down fast enough once thermoregulation has failed. Watching and waiting substitutes observation for treatment in a condition measured in minutes.

Correct Answer: Pulls the pinna down and back

A child under three has a short, upward-angled canal, so drawing the pinna down and back straightens it and lets the probe face the tympanic membrane. Poor alignment is the usual cause of falsely low readings. Option a is incorrect because the up and back maneuver belongs to adults and children older than three, whose ear canals angle differently. Used on a toddler it aims the probe at the canal wall. Option b is incorrect because pulling straight outward does nothing to open the curve of a young child's canal. Without that curve straightened the sensor reads the wall instead of the membrane and underestimates the temperature. Option c is incorrect because traction on the earlobe toward the cheek is not a recognized step for any age group. The landmark that must move is the pinna, and it moves downward in a toddler.

Correct Answer: Arterial pressure while the ventricles are relaxed

Diastolic pressure is the lowest arterial pressure, present while the ventricles relax and refill and the aortic valve is closed. It reflects peripheral resistance, and the coronary arteries fill during this phase. Option a is incorrect because the pressure generated as the ventricles squeeze blood into the aorta is the systolic value, the top number. It reflects stroke volume and the stiffness of the arteries. Option b is incorrect because the mean arterial pressure describes the average driving force over a whole cycle. It is a separate calculated figure, and it sits nearer the diastolic than halfway between the two. Option d is incorrect because subtracting one recorded number from the other yields the pulse pressure. Pulse pressure is a derived value used to judge stroke volume, and it is not charted as the bottom number.

Correct Answer: A systolic fall of twenty-two millimeters of mercury

Orthostatic hypotension is a fall of at least twenty millimeters of mercury systolic or at least ten diastolic within three minutes of standing. Either criterion alone is enough, and a systolic drop of twenty-two qualifies. Option b is incorrect because the diastolic threshold is ten millimeters of mercury, and six falls short. The two thresholds are easy to swap, so anchor the larger number to the larger pressure. Option c is incorrect because twelve points of systolic drop sits under the required twenty. A change that size may still be worth watching in a frail client, but it does not meet the criterion. Option d is incorrect because the supporting heart rate finding is a rise of thirty beats or more, not a fall. A pulse that drops on standing suggests a different problem entirely.

Correct Answer: Increase the flow rate until the bag inflates

A bag that fully deflates on inspiration means the client is drawing in more gas than the flow supplies and may rebreathe carbon dioxide. Raising the flow keeps the reservoir partly inflated throughout the cycle. Option a is incorrect because strap tension affects skin over the nose and cheeks, not the volume of gas reaching the reservoir. Loosening the strap would break the seal and lower the delivered concentration further. Option c is incorrect because switching devices drops this client from roughly ninety percent oxygen to well under half that amount. A correctable flow problem does not justify abandoning the ordered therapy. Option d is incorrect because a collapsing reservoir is a device failure in progress, and charting it without acting leaves the client under oxygenated. Monitoring alone answers none of what the assessment has already shown.

Correct Answer: Family history makes changing sodium, weight and activity more important.

Family history is a non-modifiable risk factor, but it raises the value of the factors the client can change. Sodium reduction, weight loss, activity, tobacco cessation and adherence all remain fully within the client's control. Option a is incorrect because it confirms the client's hopelessness and is factually wrong. Lifestyle change and medication lower pressure effectively in clients with a strong family history, and abandoning treatment invites target organ damage. Option b is incorrect because drug therapy is only part of the plan. Current guidance pairs medication with the DASH eating pattern, sodium restriction, weight management and exercise, and this answer quietly excuses the client from all of that. Option d is incorrect because periodic screening suits a person without the diagnosis. This client already has hypertension, so the plan needs active treatment and regular monitoring rather than a check every few years.

Correct Answer: One eighty over eighty-eight

The first Korotkoff sound is the systolic pressure and the final disappearance is the diastolic. The silent window between them is an auscultatory gap, which is documented but is neither of the two recorded values. Option b is incorrect because taking the return of sound as the systolic is the classic gap error. It understates the true systolic by forty points and can label a hypertensive client normal. Option c is incorrect because the point where the sounds first vanish is not the diastolic. Stopping there mistakes the top of the gap for phase five and grossly overstates the lower number. Option d is incorrect because the number chosen for the systolic here is where the sounds stopped, not where they began. Systolic is always read at the first of at least two consecutive taps.

Correct Answer: Hyperoxygenate and allow the client to rest

Between passes the client is reoxygenated with one hundred percent oxygen and given thirty to sixty seconds to recover before another pass. The saturation and heart rate need to return toward baseline first. Option a is incorrect because a second pass on a client already at eighty-eight percent drives the saturation lower still. Each pass removes oxygen along with the mucus, and the recovery interval exists precisely to prevent that. Option b is incorrect because abandoning the procedure leaves audible secretions sitting in the airway. Up to three passes are permitted in one episode, so the nurse still has room to clear this client safely. Option c is incorrect because raising the pressure attacks the wrong problem entirely. Desaturation reflects lost ventilation time, not weak suction, and pressure above one hundred fifty millimeters of mercury adds mucosal injury to the hypoxia.

Correct Answer: Measure the pressure in a lower extremity and document

Both arms are off limits, the left permanently after node dissection and the right because of the infusion. A thigh or calf measurement with a properly sized cuff is obtained and the site is documented. Option a is incorrect because the restriction after axillary node dissection never expires. Disrupted lymphatic drainage leaves that limb prone to lymphedema and infection for life, so cuffs, venipuncture and injections are all avoided there. Option c is incorrect because stopping an ordered infusion to take a routine reading interrupts therapy for no good reason. Cuff inflation over an intravenous site also risks backflow, occlusion and infiltration. Option d is incorrect because skipping the measurement leaves a gap in the record and in the client's trend. Alternative sites exist, and choosing one keeps the assessment complete without endangering either arm.