Nursing Elites

1. When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?

• A. The body temperature of the older adult is lower than that of a younger adult.
• B. An older adult's body temperature is approximately the same as that of a young child.
• C. Body temperature varies based on the type of thermometer used.
• D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.

Correct answer: A

Rationale: When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2�C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.

2. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?

• A. Help client into the chair more quickly
• B. Document client's vital signs taken just prior to moving the client
• C. Help client back to bed immediately
• D. Observe client's skin color and take another set of vital signs

Correct answer: D

Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.

3. Which of the following diseases would require the nurse to wear an N95 respirator as part of personal protective equipment?

• A. Human immunodeficiency virus
• B. Clostridium difficile enterocolitis
• C. Vancomycin-resistant enterococcus
• D. Measles

Correct answer: D

Rationale: Infections that require airborne precautions necessitate the use of an N95 respirator, a type of mask that filters particles that are 5 micrograms or smaller. Illnesses that require airborne precautions include Measles, Varicella, Severe Acute Respiratory Syndrome (SARS), and tuberculosis. Measles is a highly contagious airborne disease caused by a virus. It can spread through respiratory droplets when an infected person coughs or sneezes. Wearing an N95 respirator helps prevent the nurse from inhaling these infectious particles. Human immunodeficiency virus, Clostridium difficile enterocolitis, and Vancomycin-resistant enterococcus do not require the use of an N95 respirator as they are not transmitted through the air but have other modes of transmission.

4. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

• A. Client will be able to turn self by day 3
• B. Skin will remain intact and without redness during hospital stay
• C. Client will state pain relieved within 30 minutes after medication
• D. Pressure will be prevented by repositioning client every 2 hours

Correct answer: B

Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.

5. Which of the following is a fat-soluble vitamin?

• A. Vitamin C
• B. Vitamin D
• C. Vitamin B-6
• D. Riboflavin

Correct answer: B

Rationale: The correct answer is Vitamin D. Fat-soluble vitamins are those that can be stored in the body, allowing excess amounts to be stored for later use. While this storage ability can help prevent deficiencies, it also poses a risk of toxicity. The fat-soluble vitamins are A, E, D, and K. Choice A, Vitamin C, is water-soluble, not fat-soluble. Choice C, Vitamin B-6, and Choice D, Riboflavin, are also water-soluble vitamins and not fat-soluble.

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