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.
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Related Questions
Correct Answer is B
Explanation
A. Pleural effusion: A pleural effusion is the accumulation of fluid in the pleural space and is not directly related to atelectasis. Atelectasis is alveolar collapse and does not cause fluid buildup.
B. Hypoxemia: Atelectasis impairs gas exchange, leading to decreased oxygen levels (hypoxemia) due to collapsed alveoli. This is a hallmark finding.
C. Dysphagia: Dysphagia (difficulty swallowing) is not a direct symptom of atelectasis. It may be seen in stroke or esophageal disorders.
D. Apnea: Apnea (cessation of breathing) is not a typical sign of atelectasis. Atelectasis causes shallow breathing, dyspnea, and hypoxia rather than complete cessation.
Correct Answer is C
Explanation
A. Assess the pedal pulses for a full minute. Pedal pulses assess circulation to the lower extremities and are not related to confirming an irregular heart rate.
B. Assess the apical pulse with a Doppler device. A Doppler is not typically necessary to assess the apical pulse unless pulses are difficult to detect due to poor circulation.
C. Assess the apical pulse for a full minute. When an irregular radial pulse is detected, the most accurate way to assess heart rate and rhythm is by auscultating the apical pulse for a full minute. This helps determine the presence of arrhythmias.
D. Assess the pedal pulses with a Doppler device. Checking pedal pulses with a Doppler is useful for assessing circulation in the lower extremities but does not help confirm an irregular heart rate.
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