Nursing Elites

1. What intervention should the PN implement when taking the rectal temperature of an adult client?

• A. Lubricate the tip of the thermometer with a water-based gel.
• B. Gently insert the thermometer 1 inch into the rectum.
• C. Hold the thermometer in place the entire time while taking the temperature.
• D. Place the client in the left lateral position.

Correct answer: C

Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.

2. After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?

• A. Avoid lifting heavy objects for at least a week.
• B. Follow a low-fat diet.
• C. Monitor the incision sites for signs of infection.
• D. Resume normal activities as tolerated.

Correct answer: C

Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.

3. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?

• A. Apply a pulse oximeter
• B. Measure blood pressure
• C. Notify the charge nurse
• D. Observe pressure areas

Correct answer: C

Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.

4. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?

• A. Protect the client's feet from injury
• B. Apply a heating pad to affected area
• C. Keep the client's feet elevated
• D. Assess the feet and legs for jaundice

Correct answer: A

Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.

5. The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate?

• A. They are irregular
• B. They are usually felt in the abdomen
• C. They start in the back and radiate to the abdomen
• D. They become more intense during walking

Correct answer: B

Rationale: The correct statement about prelabor contractions (Braxton Hicks contractions) is that they are usually felt in the abdomen. They are irregular in nature and do not intensify with movement. Choice A is incorrect because prelabor contractions are irregular, not regular. Choice C is incorrect as prelabor contractions do not start in the back and radiate to the abdomen. Choice D is incorrect as prelabor contractions do not become more intense during walking.

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