It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

the beginning of each shift.

admission to the unit.

discharge.

the patient's wakening in the morning.

Answer and Explanation

The Correct Answer is A

A.   Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B.   While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C.   At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D.   While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.

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Correct Answer is C

Explanation

A. Keeping the patient on bed rest is appropriate as it conserves energy and helps prevent further heat loss.
B. Providing additional blankets is a correct intervention to warm the patient gradually.
C. Increasing muscle activity is contraindicated because it could cause vasoconstriction and worsen hypothermia, as the body focuses on preserving core temperature.
D. Offering fluids (if permitted) is correct as hydration can help restore normal body temperature regulation.

A. rinse the thermometer with water. B. dry the thermometer with a dry cotton ball. C. wipe the thermometer with alcohol. D. shake down the galinstan alloy to below normal.

Correct Answer is D

Explanation

A. Rinsing the thermometer with water is not necessary to ensure an accurate reading. The thermometer should be cleaned after use but rinsing with water does not directly ensure accuracy.
B. Using a dry cotton ball to dry the thermometer is unnecessary and could leave fibers on the device that may interfere with reading accuracy.
C. Wiping the thermometer with alcohol helps sanitize it but does not directly influence the accuracy of the reading.
D. Shaking down the galinstan alloy to below normal is necessary to reset the thermometer before use, ensuring that the mercury level is accurate when taking a new temperature.

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It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

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