Nokea
The nurse is taking the client's temperature. What should the nurse do to correctly obtain the temperature with a tympanic thermometer?
- A. Ensure that the probe tip seals the ear canal prior to taking a temperature.
- B. Irrigate the ear canal with sterile saline before obtaining the temperature.
- C. When inserting the thermometer in the adult ear, pull downward on the pinna.
- D. Check to be sure that the client does not have any tympanostomy tubes in place.
Correct Answer: A
Rationale: A: Sealing the ear canal ensures accurate readings. B: Irrigation is unnecessary and affects results. C: The pinna is pulled upward in adults. D: Tympanostomy tubes don't affect readings after initial placement.
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Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
A client's postoperative pain seems to be getting worse instead of better. When the nurse asks the client, 'Why do you think it's getting worse?' the client replies, 'My wife died last month. It's all I can think about.' The nurse must now consider:
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct Answer: D
Rationale: The client's grief over his wife's death is likely exacerbating his pain perception, requiring grief and loss interventions to address the affective component.
The client is receiving 2 liters of oxygen by nasal cannula. Which rationale should the nurse use to explain the reason for oxygen being bubbled through a humidifier?
- A. Prevents the burning sensation of direct oxygen
- B. Prevents the drying of the nasal passages
- C. Prevents a chemical reaction between the tubing and oxygen
- D. Prevents contamination with environmental gases
Correct Answer: B
Rationale: B: Humidification prevents nasal passage drying. A: Oxygen doesn't burn. C: No chemical reaction occurs with tubing. D: Environmental gases don't contaminate oxygen.
Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. all body assessment, including the feet and nails.
- B. the essential lab work of the client.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only.
Correct Answer: C
Rationale: The nail beds and the tissue surrounding the nails should be assessed for abnormal discoloration, lesions, paronychia (infection of tissue surrounding the nail), tissue dryness, breaks in the skin, pressure areas, or other abnormal appearances.
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.