Nokea
Which of the following statement best describe disability?
- A. Temporary loss of function
- B. Permanent loss of function
- C. Absence of disease
- D. A state of well being
Correct Answer: B
Rationale: Disability is permanent loss of function (B), per definition e.g., amputation impact. Temporary (A) is impairment, absence (C) health, well-being (D) opposite. B best defines disability's chronicity, making it correct.
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A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature?
- A. Oral
- B. Axillary
- C. Arterial line
- D. Rectal
Correct Answer: B
Rationale: Axillary avoids the oral route post-surgery and is appropriate for a flushed, warm client.
The most important nursing intervention to correct skin dryness is:
- A. Avoid bathing the patient until the condition is remedied, and notify the physician
- B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
- C. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection
- D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas
Correct Answer: D
Rationale: Hydration, gentle soap, and lotion address dryness and prevent cracking.
Considered as the most accessible and convenient method for temperature taking
- A. Oral
- B. Rectal
- C. Tympanic
- D. Axillary
Correct Answer: A
Rationale: Oral temperature is most accessible e.g., quick placement under tongue requiring minimal prep, unlike rectal (invasive), tympanic (equipment), or axillary (longer). Convenient for alert patients, it's standard in clinics, per nursing practice, balancing ease and reliability for routine monitoring.
Which of the following statement is true regarding temperature?
- A. Oral temperature is more accurate than rectal temperature
- B. The bulb used in Rectal temperature reading is pear shaped or round
- C. The older the person, the higher his BMR
- D. When the client is swimming, BMR Decreases
Correct Answer: B
Rationale: Rectal thermometer bulbs are pear-shaped or round (B), ensuring safety, per equipment design. Oral isn't more accurate (A) rectal is. Older age lowers BMR (C), swimming increases it (D). B is factually true, making it correct.
When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
- A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
- B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
- C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
- D. Clients need to be assessed and the care documented at least once every hour during the shift.
Correct Answer: C
Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.