Nursing Elites

1. A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?

• A. Store the glasses in a labeled case.
• B. Clean the glasses with hot water
• C. Clean the glasses with a paper towel.
• D. Store the glasses on the bedside table.

Correct answer: A

Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.

2. A 38-year-old patient’s vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?

• A. Respiratory rate only
• B. Temperature only
• C. Pulse rate and temperature
• D. Temperature and respiratory rate

Correct answer: D

Rationale: Both an elevated temperature and an increased respiratory rate are abnormal vital signs that could indicate an underlying health issue. Reporting both of these findings is crucial to ensure appropriate evaluation and intervention if needed.

3. What term refers to the manner of walking?

• A. Gait
• B. Range of motion
• C. Flexion and extension
• D. Hopping

Correct answer: A

Rationale: Gait specifically refers to the manner in which a person walks. It encompasses the pattern, rhythm, and style of walking, making it the most appropriate term in this context. Choices B, C, and D are incorrect. Range of motion refers to the extent of movement of a joint, flexion and extension relate to bending and straightening movements at a joint, and hopping is a specific type of movement that involves jumping on one foot.

4. Which of the following measures is not recommended to prevent pressure ulcers?

• A. Massaging the reddened area with lotion
• B. Using a water or air mattress
• C. Adhering to a schedule for positioning and turning
• D. Providing meticulous skin care

Correct answer: A

Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.

5. After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping, and muscle weakness. These symptoms probably indicate that the patient is experiencing:

• A. Hypokalemia
• B. Hyperkalemia
• C. Anorexia
• D. Dysphagia

Correct answer: A

Rationale: The symptoms of fatigue, muscle cramping, and muscle weakness in a patient after starting furosemide therapy are indicative of hypokalemia. Furosemide is a loop diuretic that can lead to potassium depletion, causing hypokalemia. Hypokalemia can manifest with muscle weakness, cramps, and fatigue due to alterations in neuromuscular function and decreased ATP production.

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