Nursing Elites

1. A nurse is reviewing the basal body temperature method with a couple. Which of the following statements would indicate that the teaching has been successful?

• A. I don't need to buy a special type of thermometer.
• B. I need to wait 5 minutes after smoking a cigarette before I take my temperature.
• C. I need to take my temperature before I get out of bed in the morning.
• D. I need to take my temperature at least once every day.

Correct answer: C

Rationale: The correct answer is C. Basal body temperature must be taken before getting out of bed in the morning to get an accurate reading, as even slight activity can raise body temperature and affect the results. Choice A is incorrect because a special type of thermometer is not required for basal body temperature measurement. Choice B is incorrect because smoking can affect body temperature, but the timing mentioned is not relevant to basal body temperature measurement. Choice D is incorrect because while it is essential to take the temperature consistently each day, the duration of temperature measurement is not specified, making this choice less specific compared to the correct answer.

2. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?

• A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
• B. Assessing the color of the infant’s hands and feet
• C. Assessing the infant’s tongue
• D. Assessing the infant’s arms and legs

Correct answer: A

Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.

3. A client who is post-operative from a carotid endarterectomy is experiencing difficulty swallowing. What is the nurse's priority action?

• A. Administer a prescribed antiemetic.
• B. Assess the client’s airway and respiratory status.
• C. Elevate the head of the bed.
• D. Encourage the client to take small sips of water.

Correct answer: B

Rationale: The correct answer is to assess the client’s airway and respiratory status (Choice B). Difficulty swallowing after carotid endarterectomy could indicate swelling or nerve damage affecting swallowing, which may compromise the airway. Assessing the airway and respiratory status is crucial to ensure the client's ability to breathe. Administering an antiemetic (Choice A) is not the priority as the primary concern is airway patency. Elevating the head of the bed (Choice C) can help with swallowing difficulties but does not address the immediate risk to the airway. Encouraging the client to take small sips of water (Choice D) is contraindicated if there is a risk of compromised airway due to swallowing difficulties.

4. Which hormone is primarily responsible for the regulation of calcium and phosphate in the blood?

• A. Parathyroid hormone
• B. Insulin
• C. Cortisol
• D. Thyroxine

Correct answer: A

Rationale: Parathyroid hormone is the correct answer. It regulates calcium and phosphate levels in the blood by increasing calcium reabsorption in the kidneys and releasing calcium from bones. Insulin is involved in glucose metabolism, not calcium and phosphate regulation. Cortisol is a stress hormone and is not primarily responsible for regulating calcium and phosphate levels. Thyroxine is a thyroid hormone that primarily regulates metabolism, not calcium and phosphate in the blood.

5. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

• A. Notify the healthcare provider or charge nurse immediately
• B. Offer to reschedule the treatment for the following week
• C. Plan to monitor the client's vital signs every 30 minutes
• D. Reinforce the need for extra rest periods and plenty of sleep

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

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