the most accurate reading for a temperature is done

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. The most accurate reading for a temperature is done:

A. Orally
B. Aurally through a clean canal
C. Rectally
D. Axially

Correct answer: B

Rationale: Aural readings are done through the ear canal. The tympanic membrane shares a blood supply with the hypothalamus, the brain area that regulates body temperature. Taking the temperature aurally through a clean canal ensures an accurate reading. Choice A (Orally) is not the most accurate method for temperature measurement as it can be affected by external factors like drinking hot or cold liquids. Choice C (Rectally) is invasive and less practical for routine temperature monitoring. Choice D (Axially) is not a standard method for temperature measurement and may not provide accurate results.

2. The abbreviation ac is defined as _____________.

A. before the meal
B. with the meal
C. after the meal
D. ante cibum

Correct answer: A

Rationale: The correct answer is 'before the meal.' The abbreviation 'ac' is derived from the Latin term 'ante cibum,' which translates to 'before a meal.' Choices B, C, and D are incorrect because 'ac' does not refer to 'with the meal,' 'after the meal,' or 'ante corpis.' It specifically denotes something occurring before a meal, making option A the correct choice in this context.

3. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

A. The child is asked to undress from the waist up.
B. The head is examined before the thorax, abdomen, and genitalia.
C. The nurse should keep in mind that a child at this age will have a sense of modesty.
D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.

Correct answer: C

Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.

4. Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

A. 240 cc
B. 120 cc
C. 8 cc
D. 0 cc because Italian ice is not a fluid

Correct answer: A

Rationale: The correct answer is 240 cc. Italian ice is considered a fluid, so you would record the intake of 240 cc. Choice B (120 cc) and Choice C (8 cc) are incorrect as they do not reflect the correct amount of fluid intake from an 8-ounce cup of Italian ice. Choice D (0 cc) is incorrect because Italian ice does count as a fluid intake and should be recorded as such.

5. Your patient who had AIDS/HIV has just died. Should you still use standard precautions as you provide post-mortem care?

A. Yes, because the virus is still transmissible
B. Yes, because respect must still be maintained
C. No, because the virus is no longer transmissible
D. No, because it is disrespectful

Correct answer: A

Rationale: Yes, you should still use standard precautions even after an HIV/AIDS patient has died. The virus can remain infectious after death, and healthcare workers need to protect themselves from potential exposure. Choice B is incorrect because while respect is important, the primary reason for using standard precautions is to prevent transmission of infectious diseases. Choice C is incorrect as the virus can still be transmissible even after the patient's death. Choice D is incorrect as using standard precautions is a matter of infection control, not a question of respect.