Correct Answer: B

Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.

Correct Answer: A

Rationale: Sherry is a type of fortified wine produced in Spain. It is not associated with the development of hyperkalemia, which is a condition characterized by high levels of potassium in the blood. Hyperkalemia is commonly caused by kidney dysfunction, certain medications, or excessive intake of potassium-rich foods. Drinking Sherry is not likely to cause hyperkalemia. On the other hand, Sherry consumption can potentially contribute to tooth decay, gastric ulcers, and rectal bleeding due to its acidity and alcohol content.

Correct Answer: B

Rationale: Sundowning is a phenomenon commonly seen in elderly individuals, particularly those with cognitive impairments like dementia, where they become more restless, anxious, confused, or agitated during late afternoon and evening hours, typically around sunset. This change in behavior can manifest as increased confusion, wandering, aggression, or vocalization. The exact cause of sundowning is not completely understood but may involve a combination of factors such as disruptions in the sleep-wake cycle, fatigue, decreased lighting, and hormonal imbalances. Managing sundowning behaviors may involve environmental modifications, maintaining a regular routine, ensuring proper lighting, and addressing any underlying medical conditions contributing to the behavior changes.

Correct Answer: B

Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.

Correct Answer: A

Rationale: Grilled chicken breast is a suitable choice for a low-phosphorus diet because poultry is typically lower in phosphorus compared to dairy products (like cheese), nuts (like almonds), and whole grains (like wheat toast). This option indicates an understanding of the need to restrict phosphorus intake, which is important for individuals with chronic kidney disease to prevent complications.