a nurse is caring for a client who died approximately one hour ago the nurse notes that the clients temperature has decreased in the last hour since h
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?

Correct answer: C

Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.

2. Where is the Loop of Henle located in the body?

Correct answer: B

Rationale: The Loop of Henle is a crucial structure found in the kidneys. It plays a vital role in the concentration of urine by creating a concentration gradient in the renal medulla. Choices A, C, and D are incorrect because the Loop of Henle is not located in the liver, heart, or ear. Understanding the anatomical location of the Loop of Henle is essential in comprehending renal physiology and the mechanism of action of diuretic medications.

3. The Rule of Nines is used to:

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

4. The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

Correct answer: B

Rationale: The correct answer is the 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism, which requires immediate assessment and action such as oxygen administration to maintain adequate oxygenation. The other patients should also be assessed as soon as possible, but they do not present with an immediate life-threatening condition that requires urgent intervention like the patient experiencing sudden shortness of breath.

5. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

Correct answer: B

Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.

Similar Questions

When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?
What technique would the nurse use to accurately assess a rectal temperature in an adult?
You have been assigned to take an apical pulse for one of the patients on the nursing unit. How will you do this?
Which of the following questions is considered open-ended?
A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses