Under which of the following conditions should a nursing assistant not take an oral temperature on a person?

Correct Answer: D

Rationale: The correct answer is D because when a person is confused or disoriented, they may not be able to cooperate in holding the thermometer properly or keeping their mouth closed during the reading, leading to inaccurate results. Therefore, it is crucial not to take an oral temperature in such cases to ensure the accuracy of the measurement. Choice A (The person has influenza) is not a valid reason to avoid taking an oral temperature. Influenza itself does not prevent the accurate measurement of oral temperature. Choice B (The person almost certainly has a fever) does not necessarily indicate that an oral temperature should not be taken. It is still important to assess the person's temperature accurately to confirm the presence of a fever. Choice C (The person is over six years old) is irrelevant to the decision of not taking an oral temperature. Age alone does not impact the ability to take an oral temperature accurately.

Correct Answer: A

Rationale: Step 1: Encouraging fluid intake helps maintain hydration and supports normal bowel function. Step 2: Nutritious meals provide essential nutrients for overall health and aid in proper digestion. Step 3: Adequate fluid and nutrition promote regular bowel movements, preventing constipation. Step 4: Waiting to go to the bathroom can lead to urinary retention and discomfort. Summary: Choice A is correct as it supports normal elimination. Choices B, C, and D are incorrect as they can hinder normal elimination by causing dehydration, poor nutrition, and physical inactivity.

Correct Answer: C

Rationale: The correct answer is C because keeping the genital area clean is essential in preventing infection during catheter care. This step helps reduce the risk of introducing bacteria into the urinary tract, which can lead to urinary tract infections. Maintaining proper hygiene in the genital area also promotes overall comfort and well-being for the resident. A is incorrect as the drainage bag should be positioned below the level of the bladder to facilitate proper drainage. B is incorrect as disconnecting the catheter can introduce contaminants and increase the risk of infection. D is incorrect as hanging the drainage bag from the bedrail can cause backflow of urine and increase the risk of infection.

Correct Answer: D

Rationale: The correct answer is D - Red or a different color than the surrounding area. In a stage 1 pressure injury, the skin appears red or a different color due to localized damage. This indicates early tissue damage without skin breakdown. Choice A is incorrect as it refers to a stage 2 pressure injury where the skin is nonintact. Choice B describes a stage 3 or 4 pressure injury with a deep crater. Choice C is not accurate as deep purple color is not typically associated with stage 1 pressure injuries.

Correct Answer: A

Rationale: The correct answer is A: Lung strength decreases. As people age, their lung capacity decreases due to changes in lung tissue elasticity and muscle strength, leading to decreased respiratory function. This results in reduced lung strength and efficiency. Option B is incorrect as airways actually become less elastic with age, contributing to decreased lung function. Option C is incorrect as aging can lead to a weaker cough reflex. Option D is incorrect as oxygen levels in the blood do not typically increase with age; in fact, they may decrease due to reduced lung function.