Nursing Elites

1. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

• A. That means you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are becoming dilated and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.

2. The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?

• A. Use an electronic sphygmomanometer to take the BP every 30 minutes.
• B. Retake the blood pressure in the same arm, deflating the cuff slowly.
• C. Ask another healthcare provider to recheck the blood pressure to compare results.
• D. Obtain another blood pressure cuff and retake the blood pressure.

Correct answer: B

Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.

3. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

• A. Blood glucose level of 150 mg/dL.
• B. Blood pressure of 110/70 mm Hg.
• C. Serum albumin level of 3.5 g/dL.
• D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

4. When turning an immobile bedridden client without assistance, which action best ensures client safety?

• A. Securely grasp the client's arm and leg.
• B. Put bed rails up on the side of bed opposite from the nurse.
• C. Correctly position and use a turn sheet.
• D. Lower the head of the client's bed slowly.

Correct answer: B

Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.

5. When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client’s laboratory values for potassium levels will help confirm the presence of hypokalemia.

Similar Questions