Nursing Elites

1. A healthcare professional is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the healthcare professional use to obtain the temperature?

• A. Temporal
• B. Oral
• C. Rectal
• D. Axillary

Correct answer: C

Rationale: In a 2-year-old child with diarrhea and a possible ear infection, rectal temperature measurement is the most accurate reflection of core body temperature. This method provides the most reliable reading, especially in young children, as it closely reflects the core body temperature. Oral temperature may not be accurate due to the child's recent diarrhea, which can affect oral readings. Axillary temperature may not be as accurate as rectal temperature in this case. Temporal temperature measurement, although non-invasive, may not provide the most accurate core body temperature reading, especially in a child with a potential ear infection.

2. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?

• A. A client who has a new diagnosis of adrenal insufficiency
• B. A client who has heart failure
• C. A client who is receiving treatment for diabetic ketoacidosis
• D. A client who has abdominal ascites

Correct answer: B

Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.

3. The client with a diagnosis of chronic heart failure is receiving discharge teaching. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself every day at the same time.
• B. I will call my doctor if my legs swell more.
• C. I will take my water pill only when I feel short of breath.
• D. I will limit the amount of salt in my diet.

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.

4. A client with a body mass index (BMI) of 30 is seeking advice on the initial approach to a weight loss plan. What action should the nurse recommend?

• A. Plan meals with low carbohydrates and high protein
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of daily food and beverage intake
• D. Participate in a group exercise class three times a week

Correct answer: C

Rationale: Keeping a food diary is an essential practice when starting a weight loss plan as it helps in tracking calorie intake, identifying eating patterns, and making informed decisions about dietary changes. Planning meals with low carbohydrates and high protein (Choice A) can be beneficial for some individuals, but keeping a food diary is more foundational. Engaging in strenuous daily activity (Choice B) may not be sustainable for everyone and could lead to burnout or injuries. Participating in a group exercise class (Choice D) is beneficial for fitness but may not address dietary habits, which are crucial for weight loss.

5. During an admission assessment for an older adult client, what is the priority action for the nurse after gathering data and reviewing systems?

• A. Orient the client to their room.
• B. Conduct a client care conference.
• C. Review medical prescriptions.
• D. Develop a plan of care.

Correct answer: A

Rationale: The priority action for the nurse after completing the assessment and review of systems for an older adult client is to orient them to their room. This is crucial for ensuring the client's comfort and safety in the new environment. While reviewing medical prescriptions and developing a plan of care are important aspects of the admission process, they can be done after the client has been oriented to their room.

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