Nursing Elites

1. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:

• A. Infection
• B. Hypothermia
• C. Anxiety
• D. Dehydration

Correct answer: D

Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.

2. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?

• A. Low back pain.
• B. Dyspnea.
• C. Hypotension.
• D. Thready pulse.

Correct answer: B

Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.

3. Which of the following interventions promotes patient safety?

• A. Assess the patient’s ability to ambulate and transfer from a bed to a chair
• B. Demonstrate the signal system to the patient
• C. Check to see that the patient is wearing their identification band
• D. All of the above

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

4. When teaching a client with tuberculosis, which statement should the nurse include?

• A. You will need to continue taking the multi-medication regimen for 4 months.
• B. You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication.
• C. You will need to remain hospitalized for treatment.
• D. You will need to wear a mask at all times.

Correct answer: B

Rationale: Monitoring the effectiveness of tuberculosis medication is crucial to ensure the treatment is working properly. Regular sputum samples help in assessing the response to the medication. This monitoring can guide adjustments in the treatment plan if needed. Options A and C are incorrect as they do not reflect essential aspects of tuberculosis treatment. Option D is not a standard recommendation for tuberculosis treatment and may lead to misconceptions.

5. When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?

• A. Assist-control
• B. Synchronized intermittent mandatory ventilation
• C. Continuous positive airway pressure
• D. Pressure support ventilation

Correct answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

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