Nursing Elites

1. 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: D

Rationale: In cases where the oral route is contraindicated due to oral surgery or altered consciousness, the rectal method is preferred for the most accurate body temperature reading. This method is particularly useful when the skin is flushed and warm, as it provides a reliable reflection of core body temperature despite external factors affecting the skin temperature. Axillary temperature may not be as accurate as rectal temperature due to variations caused by environmental factors and technique. Arterial line temperature monitoring is invasive and not typically used for routine temperature assessment.

2. What should be done in order to prevent contamination of the environment when making a bed?

• A. Avoid flinging soiled linens
• B. Strip all linens at the same time
• C. Finish both sides at the same time
• D. Embrace soiled linen

Correct answer: A

Rationale: The correct practice to prevent contamination of the environment when making a bed is to avoid flinging soiled linens. Flinging soiled linens can spread contaminants in the environment, leading to potential health risks. By handling soiled linens properly and avoiding flinging them, the risk of contamination is minimized, ensuring a safer and cleaner environment. Stripping all linens at the same time (choice B) may not necessarily prevent contamination if the soiled linens are flung around. Finishing both sides at the same time (choice C) is unrelated to preventing contamination. Embracing soiled linen (choice D) is not hygienic and can lead to spreading contaminants.

3. When providing mouth care to an unconscious client, what is the best position for the client?

• A. Fowler’s position
• B. Side-lying
• C. Supine
• D. Trendelenburg

Correct answer: B

Rationale: The best position for an unconscious client when providing mouth care is the side-lying position. This position helps prevent aspiration by allowing fluids to drain out of the mouth easily, reducing the risk of choking or aspiration pneumonia. Placing the client in a side-lying position also promotes comfort and safety during the procedure. The other options are not ideal for mouth care in an unconscious client: Fowler’s position may increase the risk of aspiration, the supine position can lead to aspiration as well, and Trendelenburg position is not recommended due to potential adverse effects on blood circulation and increased intracranial pressure.

4. What is the primary purpose of a platelet count?

• A. Assessing clot formation potential
• B. Assessing bleeding risk
• C. Detecting antigen-antibody response
• D. Identifying cardiac enzymes presence

Correct answer: B

Rationale: A platelet count is primarily used to assess the risk of bleeding. Platelets play a crucial role in blood clotting, so a low platelet count can lead to an increased risk of bleeding. Monitoring platelet levels helps healthcare providers evaluate a patient's ability to form clots and manage bleeding.

5. Which of the following principles of primary nursing has proven most satisfying to the patient and nurse?

• A. Continuity of patient care promotes efficient and cost-effective nursing care.
• B. Autonomy and authority for planning are best delegated to a nurse who knows the patient well.
• C. Accountability is clearest when one nurse is responsible for the overall plan and its implementation.
• D. The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

Correct answer: D

Rationale: The holistic approach, encompassing a therapeutic relationship, continuity, and efficient nursing care, is the most satisfying principle of primary nursing. This approach considers the patient as a whole, taking into account physical, emotional, social, and spiritual aspects, which enhances the nurse-patient relationship and promotes comprehensive care. It emphasizes individualized care delivery, continuity of care, and an integrated approach, leading to improved patient satisfaction and nurse fulfillment.

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