Nursing Elites

1. When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

• A. Hold the thermometer in place.
• B. Place the disposable pad under the buttocks.
• C. Instruct the client to breathe deeply.
• D. Return the probe to the charger.

Correct answer: A

Rationale: When obtaining a rectal temperature with an electronic thermometer, holding the thermometer in place is crucial. This action ensures accurate temperature measurement and prevents injury to the client. Option B, placing a disposable pad under the buttocks, is not the most important action; it may enhance comfort but does not impact the accuracy of the temperature reading. Option C, instructing the client to breathe deeply, is irrelevant to obtaining a rectal temperature. Option D, returning the probe to the charger, is an incorrect action after temperature measurement.

2. The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take?

• A. Call the healthcare provider who wrote the prescription
• B. Attempt to clarify the prescriptions with the pharmacist
• C. Administer the medications as prescribed
• D. Ask another healthcare provider for clarification

Correct answer: A

Rationale: The correct action for the charge nurse to take is to call the healthcare provider who wrote the illegible prescriptions. It is crucial to clarify illegible prescriptions directly with the provider to ensure patient safety and prevent medication errors. Option B, attempting to clarify with the pharmacist, may lead to misinterpretation and is not the recommended first step. Administering the medications as prescribed without clarity can jeopardize patient safety, making option C incorrect. Asking another healthcare provider for clarification (option D) may not be effective as the responsibility lies with the provider who wrote the prescription.

3. A client with acute pancreatitis is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely?

• A. Serum potassium
• B. Serum glucose
• C. Serum triglycerides
• D. Serum calcium

Correct answer: C

Rationale: In a client with acute pancreatitis receiving total parenteral nutrition (TPN), the nurse should monitor serum triglycerides closely. Acute pancreatitis can lead to fat malabsorption, making the client susceptible to hypertriglyceridemia. Monitoring serum triglycerides is crucial to prevent complications such as hyperlipidemia. While monitoring serum potassium, glucose, and calcium levels is also essential in various conditions, in this scenario, the primary concern is the risk of developing hypertriglyceridemia due to fat malabsorption.

4. A client with a history of hypertension is admitted with a blood pressure of 200/110 mmHg. Which intervention should the nurse implement first?

• A. Administer an antihypertensive medication as prescribed.
• B. Monitor the client's urine output.
• C. Administer oxygen therapy as prescribed.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: D

Rationale: The correct answer is to obtain an arterial blood gas (ABG) sample. In a client with severe hypertension, it is essential to assess for metabolic or respiratory acidosis which can be done through an ABG sample. Administering antihypertensive medication without assessing the acid-base status of the client can lead to potential complications. Monitoring urine output and administering oxygen therapy are important interventions but are not the priority in this situation where the focus should be on assessing acidosis.

5. The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client's instructions?

• A. Avoid strenuous activity for 6 weeks.
• B. Report fresh blood in the urine.
• C. Take acetaminophen for fever of 101°F.
• D. Consume 6 to 8 glasses of water daily.

Correct answer: B

Rationale: Reporting fresh blood in the urine is crucial following a TURP procedure as it may indicate a complication such as bleeding or clot formation. This symptom requires immediate attention to prevent further complications. Choices A, C, and D are important aspects of post-TURP care, but identifying and reporting fresh blood in the urine take precedence due to its association with potential serious complications.

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