A nurse is about to take a client’s oral temperature, but the client has just consumed some ice chips. What should the nurse do next?

Wait for 30 minutes and then measure the client’s oral temperature.

Proceed to measure the client’s oral temperature immediately.

Document the inability to obtain an accurate reading of the client’s oral temperature.

Provide the client a sip of warm water and wait 5 minutes before measuring his oral temperature.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The nurse should wait for 30 minutes and then measure the client’s oral temperature. Consuming cold substances like ice chips can temporarily lower the oral temperature, leading to inaccurate readings. Therefore, it’s recommended to wait for a period of time to allow the oral temperature to return to its normal state.
Choice B rationale
Proceeding to measure the client’s oral temperature immediately after consuming ice chips would likely result in an inaccurately low reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Documenting the inability to obtain an accurate reading of the client’s oral temperature is not the best action in this situation. While it’s important to document any factors that might affect the accuracy of a temperature reading, in this case, the nurse can simply wait a period of time after the client has consumed the ice chips before taking the oral temperature.
Choice D rationale
Providing the client a sip of warm water and waiting 5 minutes before measuring his oral temperature may not be sufficient to ensure an accurate temperature reading. The mouth needs adequate time to return to its normal temperature after consuming something cold.

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale
Raised toilet seats are not a safety risk for older adults. In fact, they can help prevent falls in the bathroom by reducing the distance an individual has to move to sit down and stand up from the toilet.
Choice B rationale
Throw rugs are a safety risk for older adults. They can easily cause tripping and falling, especially if the edges are not secured.
Choice C rationale

A water heater temperature of 54.4°C (130° F) is a safety risk. Water at this temperature can cause burns, especially in older adults who may have decreased sensitivity to heat.
Choice D rationale
Bathtubs with rails are not a safety risk for older adults. Rails can provide support and stability when getting in and out of the bathtub, reducing the risk of falls.
Choice E rationale
Electric cords behind furniture are a safety risk. They can be a tripping hazard and can also pose a fire risk if they are damaged.

A. Withhold the medication until the prescribing provider is available. B. Request to speak with the provider who is covering for the prescriber. C. Contact the pharmacy and confirm that the dosage is safe to administer. D. Inform the charge nurse and administer the usual dose of the medication.

Correct Answer is B

Explanation

Choice A rationale
Withholding the medication until the prescribing provider is available could potentially put the patient at risk, especially if the medication is critical for the patient’s health and well-being.
Choice B rationale
Requesting to speak with the provider who is covering for the prescriber is the most appropriate action in this situation. This allows the nurse to clarify the prescription and ensure the safety of the patient.

Choice C rationale
Contacting the pharmacy to confirm that the dosage is safe to administer could be a part of the process, but it should not be the first step. The nurse should first contact a healthcare provider to discuss the prescription.
Choice D rationale
Informing the charge nurse and administering the usual dose of the medication without first consulting with a healthcare provider could potentially put the patient at risk.

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A nurse is about to take a client’s oral temperature, but the client has just consumed some ice chips. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

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