Nokea
Considered as the most accessible and convenient method for temperature taking
- A. Oral
- B. Rectal
- C. Tympanic
- D. Axillary
Correct Answer: A
Rationale: Oral temperature is most accessible e.g., quick placement under tongue requiring minimal prep, unlike rectal (invasive), tympanic (equipment), or axillary (longer). Convenient for alert patients, it's standard in clinics, per nursing practice, balancing ease and reliability for routine monitoring.
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When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?
- A. Class A
- B. Class B
- C. Class C
- D. Class E
Correct Answer: C
Rationale: An electrical fire requires a Class C extinguisher, designed for energized electrical equipment like appliances or wiring. Class A suits ordinary combustibles (wood), Class B handles flammable liquids, and Class E isn't standard (often confused with electrical but not U.S.-classified). Using a Class C extinguisher, typically with non-conductive agents like carbon dioxide, ensures safety by avoiding shock while extinguishing. This choice protects both the nurse and client in a healthcare setting, aligning with fire safety protocols.
Which of the following is NOT a contraindication in taking ORAL temperature?
- A. Quadriplegic
- B. Presence of NGT
- C. Dyspnea
- D. Nausea and Vomitting
Correct Answer: A
Rationale: Quadriplegia isn't an oral temp contraindication e.g., a paralyzed patient can hold a thermometer if alert. NGT (obstruction), dyspnea (breathing), and nausea (gagging) preclude it. Nurses opt for alternatives e.g., axillary per safety protocols.
When a client's skin is dry, which of the following nursing interventions would be most helpful?
- A. Limit bathing to once or twice a week.
- B. Bathing is daily, but no soap is used.
- C. Bathing daily with mineral oil added to the water.
- D. Bathing with lotion instead of water.
Correct Answer: A
Rationale: Limiting bathing to once or twice weekly prevents further drying of already dry skin, preserving natural oils. Daily bathing, even without soap or with oil, risks exacerbation, and lotion isn't a bath substitute. Nurses apply this to maintain skin integrity.
The nurse reported Mr. Gary's fall to improve safety. This is an example of?
- A. Incident reporting
- B. Documentation
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Reporting a fall is incident reporting (A) adverse event log, per definition. Documentation (B) records, promotion (C) well-being, transition (D) moves not report-specific. A fits the nurse's action for Mr. Gary's safety, making it correct.
Which of the following is the appropriate nursing intervention for a patient with a terminal illness who is passing through the acceptance stage?
- A. Allowing the patient to cry
- B. Encouraging unrestricted visiting
- C. Explaining the patient what is being done
- D. Being around though not speaking
Correct Answer: D
Rationale: In Kübler-Ross's acceptance stage, patients often seek peace, preferring quiet presence over active intervention. Being nearby without speaking respects their emotional state, offering comfort without disruption. Crying aligns with earlier stages (e.g., depression), unrestricted visiting may overwhelm, and explaining procedures suits denial or bargaining. Nurses provide silent support, aligning with the patient's need for calm reflection, enhancing dignity and comfort in end-of-life care.