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
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NCLEX-RN

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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. A patient's urine specimen tested positive for bilirubin. Which of the following is most true?

Correct answer: D

Rationale: Bilirubin is easily broken down by light, so all samples testing positive for bilirubin should be protected from light exposure. Storing the specimen in an area protected from light helps maintain the integrity of the bilirubin levels for accurate testing. Choice A is incorrect because the presence of bilirubin in urine does not necessarily indicate kidney disease. Choice B is incorrect as the exposure to light, not room temperature, affects bilirubin levels. Choice C is incorrect as the presence of bilirubin does not indicate the presence of bacteria in the specimen.

3. What is the MOST ACCURATE statement regarding the ESR test?

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

4. Which of the following is a negative outcome associated with impaired mobility?

Correct answer: B

Rationale: A client with impaired mobility may develop changes in body systems that put them at risk of further illness or injury. One negative outcome associated with impaired mobility is orthostatic hypotension, where blood pressure drops significantly when moving from a sitting or lying position to a standing position. This drop in blood pressure can lead to symptoms such as dizziness or fainting. This occurs because blood circulates more slowly or pools in the distal extremities due to impaired mobility. Choice A is incorrect because increased calcium absorption is not a typical negative outcome associated with impaired mobility. Choice C is incorrect because a decrease in mucus in the bronchi and lungs is not a common negative outcome of impaired mobility. Choice D is incorrect because thickening of vessel walls in the circulatory system is not directly associated with impaired mobility.

5. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

Correct answer: A

Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.

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