Nokea
The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel?
- A. Selecting appropriate route and device
- B. Obtaining temperature measurement at ordered frequency
- C. Being aware of the usual values for the patient
- D. Assessing changes in body temperature
Correct Answer: D
Rationale: Assessing temperature changes requires RN judgment, not delegable. NAP can select routes/devices , measure , and note norms under direction. Choice D is correct, per RN scope (e.g., NCSBN) reserving assessment for licensed nurses.
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The respiratory rate is...
- A. How many times an individual breaths in
- B. How many times an individual breaths out
- C. The number of breaths an individual takes in a minute
- D. The oxygen saturation level
Correct Answer: C
Rationale: Respiratory rate is breaths per minute , typically 12-20 for adults, counting full cycles. Inhaling or exhaling alone isn't standard. Oxygen saturation is a separate metric. Choice C is correct, per nursing definitions, a vital sign tracked to assess breathing adequacy and detect respiratory issues.
During an abdominal examination, the nurse palpates for liver enlargement. Which technique is most appropriate?
- A. Percussion to identify liver dullness.
- B. Palpation with deep pressure on the right upper quadrant.
- C. Auscultation for liver bruits.
- D. Inspection for visible pulsations.
Correct Answer: B
Rationale: The correct answer is B: Palpation with deep pressure on the right upper quadrant. This technique is appropriate because the liver is located in the right upper quadrant of the abdomen, and palpation with deep pressure allows the nurse to feel for any enlargement or abnormalities. Percussion (Choice A) is used to identify organ borders, not necessarily to assess for enlargement. Auscultation for liver bruits (Choice C) is not typically done during a routine abdominal examination for liver enlargement. Inspection for visible pulsations (Choice D) is more indicative of an abdominal aortic aneurysm, not liver enlargement.
Which of these statements is true regarding the vertebra prominens? The vertebra prominens is:
- A. The spinous process of C7.
- B. Usually nonpalpable in most individuals.
- C. Opposite the interior border of the scapula.
- D. Located next to the manubrium of the sternum.
Correct Answer: A
Rationale: The correct answer is A: The spinous process of C7. The vertebra prominens is the most prominent vertebra at the base of the neck, which is C7. This is because the spinous process of C7 is longer and more palpable than other cervical vertebrae.
Rationales for the incorrect choices:
B: Usually nonpalpable in most individuals - This is incorrect as the vertebra prominens (C7) is usually palpable due to its prominent spinous process.
C: Opposite the interior border of the scapula - This is incorrect as the vertebra prominens is located at the base of the neck, not opposite the scapula.
D: Located next to the manubrium of the sternum - This is incorrect as the vertebra prominens is located higher up in the neck than the manubrium of the sternum.
A patient referred to physical therapy with chronic low back pain has failed to make any progress toward meeting established goals in over three weeks of treatment. The physical therapist has employed a variety of treatment techniques but has yet to observe improvement. What is the most appropriate next step?
- A. Transfer the patient to another therapist's schedule.
- B. Re-examine the patient and establish new goals.
- C. Continue to modify the patient's treatment plan.
- D. Alert the referring physician to the patient's status.
Correct Answer: B
Rationale: The correct answer is B: Re-examine the patient and establish new goals. This is the most appropriate next step because if the patient has not shown progress in over three weeks, it indicates a need to reassess the current treatment plan and goals. By re-examining the patient, the therapist can identify any factors hindering progress and adjust the treatment plan accordingly. This proactive approach ensures the patient receives the most effective care.
Choice A: Transferring the patient to another therapist does not address the root cause of the lack of progress and may disrupt continuity of care.
Choice C: Simply continuing to modify the treatment plan without re-evaluating the patient may not lead to improved outcomes.
Choice D: Alerting the referring physician should be done after reassessment and establishing new goals, as the physician may require updated information but is not the immediate next step.
A nurse is assessing a client's oxygen saturation level. What is the most common method used to measure oxygen saturation?
- A. Arterial blood gas analysis
- B. Capnography monitoring
- C. Pulse oximetry
- D. Spirometry testing
Correct Answer: C
Rationale: Pulse oximetry is the most common, non-invasive method for oxygen saturation. ABG is invasive. Capnography measures CO2. Spirometry assesses lung function. Choice C is correct, per the explanation, reflecting standard nursing practice.