The patient requires temperatures to be taken every 2 hours. Which task will be the responsibility of the RN?
Assessing changes in body temperature.
Being aware of the usual values for the patient.
Obtaining temperature measurements at ordered frequency.
Using appropriate route and device
The Correct Answer is A
A. Assessing changes in body temperature. The RN is responsible for assessing trends in temperature and identifying potential clinical implications (e.g., infection, sepsis, or medication reactions).
B. Being aware of the usual values for the patient. While knowing baseline values is important, this is not solely an RN responsibility. Nursing assistants and other healthcare providers also note baseline values.
C. Obtaining temperature measurements at ordered frequency. This task can be delegated to a nursing assistant or licensed practical nurse (LPN), as it is a routine task that does not require assessment.
D. Using an appropriate route and device. While the RN ensures correct procedures are followed, this specific task can also be performed by trained assistive personnel. The RN focuses on interpretation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Your disease often makes patients lose mental status." While severe hypoxia can cause confusion, this response does not address the reason for clubbing and lacks therapeutic communication.
B. "Your disease will be helped if you pursed-lip breathe." Pursed-lip breathing helps with air trapping and exhalation in COPD, but it does not explain clubbing of the fingers.
C. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." COPD primarily affects oxygen exchange in the lungs, not necessarily blood pumping from the heart. Clubbing is due to chronic hypoxia, not poor cardiac output.
D. "Your disease doesn't send enough oxygen to your fingertips." Chronic hypoxia in COPD leads to increased capillary growth and tissue changes, resulting in clubbing of the fingers. This response is accurate and appropriately explains the cause.
Correct Answer is A
Explanation
A. Give the medication in the morning daily. Montelukast (a leukotriene receptor antagonist) is given once daily in the evening for long-term asthma control. If prescribed for allergic rhinitis, it can be given in the morning.
B. Administer the medication 2 hours before exercise. Montelukast is not a rescue medication but a maintenance drug. However, it can be prescribed for exercise-induced bronchospasm and is taken at least 2 hours before exercise when used for that purpose.
C. Administer the granules mixed with 20 ounces of water. Montelukast granules should be mixed with a small amount of soft food (e.g., applesauce, mashed carrots) or breast milk/formula but not a large volume of liquid.
D. Give the medication at the onset of wheezing. Montelukast is not a quick-relief medication and does not work immediately. Short-acting bronchodilators (e.g., albuterol) should be used for acute wheezing.
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