Nursing Elites

1. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

• A. Document the client’s temperature fluctuations
• B. Assess for flushed, warm skin consistently
• C. Measure temperature at regular intervals
• D. Use different sites for temperature measurement

Correct answer: C

Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.

2. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention 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 the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

3. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light while the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?

• A. Page the unit manager to address the situation.
• B. Close the demographic screen on the computer.
• C. Instruct the UAP to end the phone call immediately.
• D. Send a UAP into the client's room to relieve the nurse.

Correct answer: B

Rationale: The charge nurse's first action should be to close the demographic screen on the computer to protect patient confidentiality and prevent unauthorized access to sensitive information. This immediate response addresses the breach of patient privacy and ensures that patient data is secure, setting the right priority in managing the situation.

4. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is:

• A. Cuff blood pressure.
• B. Arterial pressure.
• C. Pulmonary artery pressure.
• D. Central venous pressure.

Correct answer: D

Rationale: Central venous pressure (CVP) monitoring is the most effective method to assess fluid status and the cardiovascular system in a client with severe burns. Severe burns can lead to significant fluid shifts and hemodynamic changes, making central venous pressure monitoring crucial for guiding fluid resuscitation and managing cardiovascular stability in these patients.

5. The healthcare provider is caring for a client diagnosed with type 2 diabetes mellitus. Which intervention should the healthcare provider implement to assess the client’s glycemic control?

• A. Monitor fasting blood glucose levels
• B. Check urine for ketones
• C. Evaluate hemoglobin A1c levels
• D. Assess the client’s dietary intake

Correct answer: C

Rationale: Evaluating hemoglobin A1c levels is the most appropriate intervention to assess glycemic control in a client with type 2 diabetes mellitus. Hemoglobin A1c levels reflect the average blood glucose control over the past 2-3 months, providing valuable information for monitoring and managing diabetes. Monitoring fasting blood glucose levels (Choice A) is important for daily management but does not provide a long-term view like hemoglobin A1c. Checking urine for ketones (Choice B) is more relevant for assessing diabetic ketoacidosis. Assessing dietary intake (Choice D) is crucial for overall diabetes management but does not directly assess glycemic control.

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