Nursing Elites

1. While measuring a client’s oral temperature using an electronic thermometer, what action should the nurse take?

• A. Assist the client with oral hygiene before taking the temperature.
• B. Inquire whether the client has smoked in the last 30 minutes.
• C. Connect the red tip probe to the thermometer unit.
• D. Position the probe tip against the client’s buccal mucosa.

Correct answer: B

Rationale: The correct action for the nurse to take when measuring a client’s oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.

2. The client is advised to take dexamethasone (Decadron) with food or milk. What is the physiological basis for this advice?

• A. Inhibits pepsin production
• B. Stimulates hydrochloric acid production
• C. Delays stomach emptying time
• D. Reduces hydrochloric acid production

Correct answer: B

Rationale: The correct answer is B: Stimulates hydrochloric acid production. Dexamethasone can stimulate the production of hydrochloric acid in the stomach, which may lead to irritation of the stomach lining. Taking dexamethasone with food or milk helps to neutralize or buffer the acid, reducing the risk of stomach irritation. Choice A is incorrect because dexamethasone does not inhibit pepsin production. Choice C is incorrect as dexamethasone does not slow stomach emptying time. Choice D is incorrect as dexamethasone does not reduce hydrochloric acid production.

3. A healthcare professional in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. Which of the following findings should the healthcare professional identify as an indication that the client has an infection?

• A. WBC 15,000/mm³
• B. Hemoglobin 12 g/dL
• C. Platelet count 300,000/mm³
• D. Sodium 140 mEq/L

Correct answer: A

Rationale: An elevated white blood cell count (WBC 15,000/mm³) is a common indicator of infection as the body increases WBC production to fight off pathogens. In conditions like infections, inflammation, or stress, the WBC count can rise. The other options, hemoglobin, platelet count, and sodium levels, are not typically specific indicators of infection. Hemoglobin measures the oxygen-carrying capacity of red blood cells, platelet count assesses clotting ability, and sodium levels indicate electrolyte balance.

4. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?

• A. Give the client information about immunization against meningitis.
• B. Tell the client to have a TB skin test every 2 years.
• C. Determine the client’s health risks.
• D. Teach the client about exercise recommendations.

Correct answer: C

Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.

5. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

• A. “The temperature around the IV site is cooler.”
• B. “The rate of the infusion increases.”
• C. “The skin at the IV site is red.”
• D. “The IV dressing is damp.”

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

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