Nokea
Which finding best indicates that the sponge bath is having a therapeutic effect on the client?
- A. The client feels more comfortable.
- B. The client begins sweating profusely.
- C. The client's temperature is 101°F (38.3°C).
- D. The client's skin is flushed.
Correct Answer: C
Rationale: A reduced temperature (101°F) directly indicates the sponge bath is effectively lowering the client's fever.
You may also like to solve these questions
The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem is the highest priority?
- A. Wound infection.
- B. Hemorrhage.
- C. Respiratory distress.
- D. Knowledge deficit.
Correct Answer: C
Rationale: Respiratory distress (C) is life-threatening post-laryngectomy, a priority. Infection (A), hemorrhage (B), and knowledge deficit (D) are secondary.
You're educating a patient how to use a peak flow meter to help monitor the status of their asthma. Which statement by the patient demonstrates they understand how to use the device?
- A. This device will help keep my lungs strong so I don't have another asthma attack.
- B. I will inhale as hard as I can while using the device.
- C. I will use this device at the same time, either in the morning or before bedtime, and compare the readings with my personal best reading.
- D. I will notify the doctor if my peak flow rating is 90% or more than my personal best peak flow.
Correct Answer: C
Rationale: Correct use involves measuring peak flow at consistent times and comparing to personal best to monitor asthma control. Inhaling is incorrect, and a high reading is not a concern.
The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube used for bolus feedings. Which intervention should the nurse include in the plan of care?
- A. Inspect the insertion line at the naris prior to instilling formula.
- B. Elevate the head of the bed (HOB) after feeding the client.
- C. Place the client in the Sims position following each feeding.
- D. Change the dressing on the feeding tube every three (3) days.
Correct Answer: B
Rationale: Elevating HOB post-feeding (B) prevents aspiration in PEG clients. Naris inspection (A) applies to NG tubes, Sims position (C) is not standard, and dressings (D) are changed PRN.
An adult is admitted with chronic obstructive pulmonary disease [COPD]. The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
- A. Pneumothorax
- B. Cor pulmonale
- C. Cardiogenic shock
- D. Left-sided heart failure
Correct Answer: B
Rationale: Neck vein distention and peripheral edema indicate right-sided heart failure, or cor pulmonale, caused by pulmonary hypertension in COPD.
To evaluate the significance of the client's bleeding, which additional assessment is most important for the nurse to make at this time?
- A. Count the pulse rate.
- B. Listen to heart sounds.
- C. Check the pupillary response.
- D. Measure the chest expansion.
Correct Answer: D
Rationale: Measuring chest expansion helps assess for complications like pneumothorax, which could cause bleeding post-bronchoscopy.