Nokea
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: D
Rationale: In cases where the oral route is not recommended due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate, and arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.
You may also like to solve these questions
Which term is best described as a systematic, rational method of planning and providing nursing care for individuals, families, groups, and communities?
- A. Assessment
- B. Nursing Process
- C. Diagnosis
- D. Implementation
Correct Answer: B
Rationale: The nursing process is a systematic, rational method that guides nurses in planning and delivering patient care. It involves a series of steps including assessment, diagnosis, planning, implementation, and evaluation. By utilizing the nursing process, nurses can provide individualized care tailored to the specific needs of patients, families, groups, and communities.
A client complains of difficulty swallowing when the nurse tries to administer capsule medication. Which of the following measures should the nurse take?
- A. Dissolve the capsule in a glass of water
- B. Break the capsule and give the contents with applesauce
- C. Check the availability of a liquid preparation
- D. Crush the capsule and place it under the tongue
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the best description of resonance?
- A. Sounds created by air-filled lungs
- B. Short, high-pitched, and thudding
- C. Moderately loud with a musical quality
- D. Drum-like
Correct Answer: A
Rationale: Resonance refers to the quality of sound produced by vibrations that are reinforced by other vibrations of the same frequency. In the context of the human body, resonance is often associated with sounds produced by air-filled structures like the lungs, vocal cords, and resonating cavities. Therefore, the best description of resonance from the given options is 'Sounds created by air-filled lungs.' This choice aligns with the concept of resonance as it relates to sound production in the human body.
Which of the following clusters of data belong to Maslow's hierarchy of needs?
- A. Love and belonging
- B. Physiological needs
- C. Self-actualization
- D. All of the above
Correct Answer: D
Rationale: Maslow's hierarchy of needs is a theory in psychology that categorizes human needs into five levels. These levels, from the most fundamental to the highest, are physiological needs, safety needs, love and belongingness, esteem needs, and self-actualization. Therefore, all the clusters listed in the choices - love and belonging, physiological needs, and self-actualization - correspond to different levels within Maslow's hierarchy of needs. Choosing 'All of the above' (option D) is the correct answer as it includes all the clusters associated with Maslow's theory.
What is the most appropriate nursing order for a patient who develops dyspnea and shortness of breath?
- A. Maintain the patient on strict bed rest at all times
- B. Maintain the patient in an orthopneic position as needed
- C. Administer high-flow oxygen immediately
- D. Encourage the patient to engage in vigorous physical activity
Correct Answer: B
Rationale: Maintaining the patient in an orthopneic position as needed is the most appropriate nursing order for a patient experiencing dyspnea and shortness of breath. This position helps to optimize lung expansion, improve oxygenation, and alleviate breathing difficulties. It is a strategic intervention to enhance respiratory function in patients with respiratory distress.