Nursing Elites

1. When measuring a patient's body temperature, what factor should be considered that can influence the temperature?

• A. Constipation
• B. Diurnal cycle
• C. Nocturnal cycle
• D. Patient's emotional state

Correct answer: B

Rationale: When measuring body temperature, it is essential to consider factors that can influence it. The diurnal cycle, which refers to the body's natural temperature variations throughout a 24-hour period, can impact body temperature readings. Factors like exercise, age, and environment can also affect body temperature. Constipation does not directly influence body temperature. The 'nocturnal cycle' is not a recognized term in relation to body temperature. While a patient's emotional state can affect vital signs, it is not a primary factor in influencing body temperature measurements.

2. Your patient has finished a 12-ounce can of iced tea and 8 ounces of fresh orange juice. What will you record on the Intake and Output form for this patient's intake?

• A. 20 cc
• B. 20 cm
• C. 600 cc
• D. 600 cm

Correct answer: C

Rationale: You will record 600 cc of fluid intake. There are 600 cc in 20 ounces (12 ounces of iced tea + 8 ounces of orange juice) of fluid intake. Choice A and B are incorrect as they do not reflect the correct conversion of fluid intake from ounces to cubic centimeters. Choice D is incorrect as it provides the measurement in cubic centimeters but does not account for the total fluid intake accurately.

3. When a nurse's hand comes in contact with a client's blood after providing wound care, what is the next action the nurse should take?

• A. Use an alcohol-based hand sanitizer to disinfect the hands
• B. Wash hands with soap and water using appropriate technique
• C. Notify the appropriate personnel about the exposure to client's blood
• D. Sample some of the client's blood to determine the presence of diseases

Correct answer: B

Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.

4. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?

• A. The client suddenly complains of back pain and has chills
• B. The client develops dependent edema in the extremities
• C. The client has a seizure
• D. The client's heart rate drops to 60 bpm

Correct answer: A

Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.

5. A client has applied a cold pack to their arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

• A. The skin on the arm appears mottled
• B. The cold pack has been in place for 10 minutes
• C. The client complains of feeling nauseated
• D. The capillary refill in the area distal to the arm is 2 seconds

Correct answer: A

Rationale: When using a cold pack for therapeutic purposes, it is essential to monitor the site to prevent tissue damage. Prolonged use of cold therapy can lead to pale, mottled skin with a bluish appearance. This change in skin color indicates poor circulation, and the cold pack should be removed immediately to prevent tissue injury. Choices B, C, and D are incorrect because the duration of cold pack application, client complaints of nausea, and capillary refill time do not specifically indicate the need for the cold pack to be removed due to potential tissue damage.

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