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. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?

• A. Amount of support provided by family members
• B. Measurement of pain using a scale of 0 to 10
• C. The ability to perform ADLs
• D. Nonverbal behaviors exhibited when pain occurs

Correct answer: C

Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs. While family support, pain measurement, and nonverbal behaviors are important aspects to consider in caring for a client with chronic pain, the ability to perform ADLs directly reflects the client's independence and quality of life, making it the most crucial information to obtain.

3. The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?

• A. The client reports pain at the IV site
• B. The client’s heart rate is irregular
• C. The client has swelling at the IV site
• D. The client’s blood pressure is elevated

Correct answer: B

Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.

4. What action should be taken when adding sterile liquids to a sterile field?

• A. Use an expired sterile liquid if the bottle is sealed and unopened.
• B. Consider the sterile field contaminated if it becomes wet during the procedure.
• C. Remove the container cap and place it with the inside facing up on the sterile field.
• D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

5. Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?

• A. Shaving the neck.
• B. Establishing a means of communication.
• C. Inserting a Foley catheter.
• D. Starting an IV.

Correct answer: B

Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.

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