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. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?

• A. Altered sensory perception
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.

3. The HCP gives a pregnant woman a prescription for one prenatal vitamin with iron daily and tells her that she needs to increase foods in her diet because her hemoglobin is 8.2 grams/dL. When a list of iron-rich foods is given to the client, she tells the PN that she is a vegetarian and does not eat anything that "bleeds." Which instruction should the PN provide?

• A. All below
• B. Increase green leafy vegetables in the diet
• C. Oatmeal is a good choice for breakfast
• D. Add lentils and black beans to soup

Correct answer: A

Rationale: Vegetarians can increase their iron intake through plant-based sources such as green leafy vegetables, oatmeal, and legumes, which are rich in iron.

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

• A. Protect the client's feet from injury
• B. Apply a heating pad to the 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 the most appropriate action for a client with cirrhosis experiencing peripheral neuropathy. Peripheral neuropathy can lead to a loss of sensation, making the client prone to unnoticed injuries. Applying a heating pad (Choice B) is contraindicated as it may cause burns or further damage to the affected area. Keeping the client's feet elevated (Choice C) is not directly related to managing peripheral neuropathy and may not provide significant benefit. Assessing the feet and legs for jaundice (Choice D) is important for monitoring liver function in clients with cirrhosis, but in this case, the priority is to prevent injury to the feet due to decreased sensation.

5. What is the most common cause of acute pancreatitis?

• A. Gallstones
• B. Alcohol abuse
• C. Hypertriglyceridemia
• D. Infection

Correct answer: A

Rationale: The correct answer is A: Gallstones. Gallstones are the most common cause of acute pancreatitis as they obstruct the pancreatic duct, leading to inflammation. While alcohol abuse (Choice B) can also cause pancreatitis, gallstones are more prevalent. Hypertriglyceridemia (Choice C) is a less common cause of acute pancreatitis compared to gallstones. Infection (Choice D) is not a primary cause of acute pancreatitis; gallstones are the leading etiology.

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