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. In which type of cardiomyopathy does septal involvement occur?

• A. Congestive
• B. Dilated
• C. Hypertrophic
• D. Restrictive

Correct answer: C

Rationale: Septal involvement is a characteristic feature of hypertrophic cardiomyopathy, where the septal wall of the heart thickens. This thickening can obstruct blood flow out of the heart, leading to complications such as arrhythmias and heart failure. This differentiates it from other types of cardiomyopathy. In congestive cardiomyopathy (choice A), the heart's chambers become enlarged and weakened, but there is no specific mention of septal involvement. Dilated cardiomyopathy (choice B) involves dilation and impaired contraction of the heart chambers, not specifically septal thickening. Restrictive cardiomyopathy (choice D) is characterized by stiffening of the heart muscle, affecting its ability to fill properly, without direct involvement of the septum.

3. An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan?

• A. Plan to have the same nursing staff provide care for the client whenever possible
• B. Describe the activities available to residents and encourage him to choose the ones he prefers
• C. Encourage the client to remain on the unit for three weeks until he is oriented to his new surroundings
• D. Introduce the client to the nursing staff and other residents as soon as possible

Correct answer: A

Rationale: The correct intervention for a client with Alzheimer's disease in an extended care facility is to plan to have the same nursing staff provide care whenever possible. Consistency in caregivers helps reduce confusion and anxiety in clients with Alzheimer’s disease, promoting a stable and supportive environment for the client. Choice B is incorrect as it focuses on activities rather than the consistency of caregivers. Choice C is incorrect as it suggests isolating the client, which can lead to increased confusion and distress. Choice D is incorrect as introducing the client to new people immediately can be overwhelming and may exacerbate their symptoms.

4. At one minute after birth, an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What is the Apgar score?

• A. 4
• B. 6
• C. 8
• D. 10

Correct answer: C

Rationale: The Apgar score is based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a heart rate over 100 (2 points), is crying (2 points indicating good respiratory effort), resists the catheter (2 points for good reflex irritability), but has acrocyanosis (partial point deduction of 1). Thus, the Apgar score at one minute after birth would be 8. Choice A is incorrect as the given signs indicate a higher score. Choice B is incorrect as the signs described support a score above 6. Choice D is incorrect as it represents a perfect score which is not the case here due to acrocyanosis.

5. After a hip replacement surgery, a client is instructed to use an abduction pillow while in bed. What is the primary purpose of this device?

• A. To reduce the risk of blood clots.
• B. To prevent hip dislocation.
• C. To improve circulation in the legs.
• D. To alleviate pain and discomfort.

Correct answer: B

Rationale: The primary purpose of using an abduction pillow after hip replacement surgery is to prevent hip dislocation. The abduction pillow keeps the legs separated, which reduces the risk of hip dislocation by preventing excessive internal rotation and adduction of the hip joint. Choices A, C, and D are incorrect as the main goal of using the abduction pillow is to maintain proper positioning and stability of the hip joint to prevent dislocation, rather than addressing blood clots, circulation, or pain relief.

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