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What technique would the nurse use to accurately assess a rectal temperature in an adult?
- A. Use a lubricated blunt tip thermometer.
- B. Insert the thermometer 2 to 3 inches into the rectum.
- C. Leave the thermometer in place for up to 8 minutes if the patient is febrile.
- D. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
Correct Answer: A
Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.
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The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?
- A. Exercise
- B. Radiation
- C. Metabolism
- D. Food digestion
Correct Answer: B
Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.
Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.
- A. head of the bed on the patient's right side
- B. head of the bed on the patient's left side
- C. bottom of the bed on the patient's right side
- D. bottom of the bed on the patient's left side
Correct Answer: B
Rationale: The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.
When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?
- A. 10
- B. 15
- C. 20
- D. 30
Correct Answer: D
Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.
When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?
- A. General health
- B. Genetic makeup
- C. Nutritional status
- D. Activity and exercise patterns
Correct Answer: A
Rationale: Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.
Patients who cannot move in their bed on their own should be turned at least ________________.
- A. once a day
- B. twice a day
- C. every 2 hours
- D. every 4 hours
Correct Answer: C
Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.