When measuring a patient's weight, the nurse is aware of which of these guidelines?
The patient may leave on his or her jacket and shoes as long as these are documented next to the weight.
The type of scale does not matter, as long as the weights are similar from day to day.
Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
The patient is always weighed wearing only his or her undergarments.
The Correct Answer is C
Choice A rationale
While documenting additional clothing could mitigate some error, the presence of a jacket and shoes adds variable, unmeasured mass. Accurate weight measurement is crucial for medication dosing, fluid balance assessment, and nutritional status monitoring. Even seemingly minor additions can significantly skew results, impacting clinical decisions and potentially leading to suboptimal patient care.
Choice B rationale
The type of scale significantly impacts accuracy and precision. Different scales, such as beam scales, electronic scales, or bed scales, have varying calibration standards and sensitivities. Using a consistent, properly calibrated scale minimizes measurement variability and ensures reliable data, which is essential for tracking trends and making valid comparisons over time in a clinical setting.
Choice C rationale
Diurnal variations in body weight occur due to factors like fluid shifts, food and fluid intake, and bowel elimination. Weighing at the same time minimizes these transient fluctuations, providing a more consistent and comparable baseline for monitoring weight changes over time. This consistency is vital for accurate assessment of a patient's fluid status, nutritional progress, or response to therapeutic interventions.
Choice D rationale
While weighing in undergarments provides the most accurate baseline, it may not always be practical or appropriate due to patient comfort, privacy concerns, or clinical urgency. The goal is to standardize the weighing procedure as much as possible, including minimizing clothing and documenting any deviations to ensure consistency and interpretability of serial weight measurements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Asking which client is supposed to have medications compromises patient privacy and could lead to medication errors if an incorrect patient self-identifies. Proper patient identification is a fundamental safety measure, requiring objective verification to ensure the right medication is administered to the right patient.
Choice B rationale
Stating the patient's name and expecting a confirmation ("You are Mrs. Wilson, aren't you?") is a leading question and does not independently verify identity. A patient could respond affirmatively without truly being Mrs. Wilson, increasing the risk of medication errors by not adhering to objective verification protocols.
Choice C rationale
Asking if anyone knows Mrs. Wilson is an inappropriate and unprofessional method for patient identification. It breaches patient confidentiality and does not provide a reliable or direct means of verifying the intended recipient of medication, potentially leading to significant medication safety issues.
Choice D rationale
Checking the client's identification bracelets while the client states their name provides two independent identifiers, which is a standard and highly reliable method for patient identification. This dual verification minimizes the risk of medication errors by confirming both physical identification and the patient's verbal confirmation before administration.
Correct Answer is D
Explanation
Choice A rationale
Asking the patient to turn their head side-to-side against resistance assesses the accessory nerve (cranial nerve XI), which innervates the sternocleidomastoid and trapezius muscles. This action tests muscle strength and integrity of the nerve pathways responsible for head and shoulder movement.
Choice B rationale
Asking the patient to stick out the tongue and move it side-to-side from midline assesses the hypoglossal nerve (cranial nerve XII). This nerve is responsible for the motor control of the intrinsic and extrinsic muscles of the tongue, crucial for speech articulation and swallowing.
Choice C rationale
Asking the patient to read the smallest set of letters on a Snellen eye chart assesses visual acuity, primarily testing the optic nerve (cranial nerve II) and the visual pathways. This evaluates the patient's ability to discern details at a distance.
Choice D rationale
Asking the patient to identify the smell of vanilla and orange peel directly assesses the olfactory nerve (cranial nerve I). This nerve is responsible for the sense of smell, and presenting distinct, non-irritating odors allows for the evaluation of its function and patency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.