Nursing Elites

1. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

• A. Place the tip of the thermometer under the center of the infant's axilla.
• B. Pull the pinna of the infant's ear forward before inserting the probe.
• C. Insert the probe 3.8 cm (1.5 inches) into the infant's rectum.
• D. Insert the thermometer in front of the infant's tongue.

Correct answer: A

Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.

2. A nurse is reviewing the medical history of a client who has angina. What risk factor should the nurse identify?

• A. Hyperlipidemia.
• B. COPD.
• C. Seizure disorder.
• D. Hyponatremia.

Correct answer: A

Rationale: The correct answer is A, Hyperlipidemia. Hyperlipidemia, characterized by high levels of lipids in the blood, is a well-established risk factor for the development of angina. Elevated lipid levels can lead to atherosclerosis, which narrows the arteries supplying the heart muscle with oxygenated blood, increasing the risk of angina. Choices B, C, and D are incorrect because COPD, seizure disorder, and hyponatremia are not directly associated with an increased risk of angina.

3. A nurse is assessing a client with a history of post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

• A. Dependence on family and friends
• B. Loss of interest in usual activities
• C. Ritualistic behavior
• D. Passive-aggressive behavior

Correct answer: B

Rationale: The correct answer is B: Loss of interest in usual activities. Clients with PTSD often exhibit symptoms such as numbing, which can manifest as a loss of interest in activities they once enjoyed. Choice A, dependence on family and friends, is more indicative of seeking support rather than a direct symptom of PTSD. Choice C, ritualistic behavior, is more commonly associated with conditions like obsessive-compulsive disorder. Choice D, passive-aggressive behavior, is not a typical finding in clients with PTSD.

4. Which electrolyte imbalance is commonly seen in patients taking furosemide?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, can lead to potassium loss in the urine, resulting in hypokalemia. This electrolyte imbalance is commonly seen in patients taking furosemide and requires close monitoring. Choices B, C, and D are incorrect because furosemide does not typically cause hyponatremia, hyperkalemia, or hypercalcemia as frequently as it causes hypokalemia.

5. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Redness and warmth in the calf
• C. Oxygen saturation of 95%
• D. Temperature of 37.3°C (99.1°F)

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.

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