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.
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What should be done in order to prevent contamination of the environment when making a bed?
- A. Avoid flinging soiled linens
- B. Strip all linens at the same time
- C. Finish both sides at the same time
- D. Embrace soiled linen
Correct Answer: A
Rationale: The correct practice to prevent contamination of the environment when making a bed is to avoid flinging soiled linens. Flinging soiled linens can spread contaminants in the environment, leading to potential health risks. By handling soiled linens properly and avoiding flinging them, the risk of contamination is minimized, ensuring a safer and cleaner environment.
The healthcare professional prepares to administer buccal medication. The medicine should be placed...
- A. On the client's skin
- B. Between the client's cheeks and gums
- C. Under the client's tongue
- D. On the client's conjunctiva
Correct Answer: B
Rationale: Buccal medication is administered by placing it between the client's cheeks and gums. This route allows for the medication to be absorbed through the mucous membranes in the mouth, providing a rapid onset of action compared to oral ingestion. Placing the medication under the tongue (sublingual) allows for absorption through the sublingual mucosa, not the buccal mucosa. Placing medication on the skin or the conjunctiva is not appropriate for buccal administration.
Which of the following is included in Orem's theory?
- A. Maintenance of a sufficient intake of air
- B. Self-perception
- C. Love and belonging
- D. Physiological needs
Correct Answer: A
Rationale: Orem's theory, also known as the Self-Care Deficit Nursing Theory, emphasizes individuals' ability to perform self-care to maintain health and well-being. One aspect of this theory is the maintenance of a sufficient intake of air, which is essential for sustaining life and overall health. This self-care component focuses on the individual's ability to meet their physiological needs, including the intake of air, to promote optimal functioning and health.
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.
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.