Nokea
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.
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The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy at home. What should the nurse include in the client's teaching regarding oxygen safety?
- A. Ensure you have a fire extinguisher readily available
- B. Keep the oxygen tubing loose to prevent tangling
- C. Avoid using electric heating devices in your home
- D. Use an oxygen concentrator for outdoor activities
Correct Answer: C
Rationale: Avoiding electric heating devices (C) is critical in COPD oxygen therapy teaching, as oxygen accelerates combustion, posing a fire risk. Fire extinguisher (A) is supplementary. Loose tubing (B) risks disruption. Concentrator use (D) depends on need. Safety education, per home care standards, prioritizes fire prevention.
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.
You are about to write an information on the Kardex. There are 4 available writing instruments to use. Which of the following should you use?
- A. Mongol #2
- B. Permanent Ink
- C. A felt or fountain pen
- D. Pilot Pentel Pen marker
Correct Answer: B
Rationale: Permanent ink (B) is required for Kardex to ensure legible, lasting records, per legal standards. Pencil (A) erases, felt/fountain pens (C) smudge, markers (D) fade. B ensures accuracy, making it correct.
All of the following are purpose of inflammation except
- A. Increase heat, thereby produce abatement of phagocytosis
- B. Localized tissue injury by increasing capillary permeability
- C. Protect the issue from injury by producing pain
- D. Prepare for tissue repair
Correct Answer: A
Rationale: Inflammation aims to protect and heal tissue, not hinder it. Increasing heat (A) enhances phagocytosis by boosting immune cell activity, not abating it, making this statement incorrect and the exception. Localized injury response (B) occurs as capillary permeability increases, delivering immune cells to the site. Pain (C) protects by discouraging movement, aiding healing. Preparing for tissue repair (D) is a key goal as inflammation clears debris and initiates recovery. The misstatement in A reverses the biological role of heat, which supports immune function rather than suppressing it, confirming A as the answer since it does not align with inflammation's purposes.
The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct Answer: D
Rationale: All are critical to monitor bleeding risks and heparin efficacy.