A nurse is in the process of taking a patient’s oral temperature.
The patient informs the nurse that they have just consumed some ice chips. What should the nurse do next?
Record that the nurse was unable to take the patient’s temperature.
Continue to take the oral temperature.
Wait for 30 minutes and then return to take the oral temperature.
Give the patient a sip of warm water, wait for 5 minutes, and then take the temperature.
The Correct Answer is C
Choice A rationale
Recording that the nurse was unable to take the patient’s temperature would not be the most appropriate action in this situation. The nurse can wait for a certain period of time and then take the patient’s temperature.
Choice B rationale
Continuing to take the oral temperature immediately after the patient has consumed ice chips could result in an inaccurately low temperature reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Waiting for 30 minutes and then returning to take the oral temperature is the most appropriate action. Consuming cold substances can lower the oral temperature temporarily, so it’s recommended to wait 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Choice D rationale
Giving the patient a sip of warm water, waiting for 5 minutes, and then taking the temperature is not the standard procedure. While it might help to normalize the temperature in the mouth more quickly, it’s generally recommended to wait at least 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Urinary retention refers to the inability to empty the bladder completely. While it can cause discomfort and bloating, it does not typically result in dark amber, cloudy urine with an unpleasant odor.
Choice B rationale
Urinary incontinence is the loss of bladder control, leading to the involuntary leakage of urine. It does not cause the urine to become dark amber, cloudy, or have an unpleasant odor.
Choice C rationale
A urinary tract infection (UTI) is an infection in any part of the urinary system — kidneys, bladder, urethra. Most UTIs are caused by bacteria, but they can also be caused by viruses or fungi. Symptoms of a UTI often include cloudy, dark, or strong-smelling urine.
Choice D rationale
Urinary frequency refers to needing to urinate more often than usual. It can be a symptom of many different issues, including a UTI, but on its own, it does not cause the urine to become dark amber, cloudy, or have an unpleasant odor.
Correct Answer is A
Explanation
Choice A rationale
The nurse should respect the patient’s need for space while also expressing willingness to talk when the patient is ready.
Choice B rationale
Telling the patient “Everything will be okay” may seem dismissive of the patient’s feelings and may not be helpful in this situation.
Choice C rationale
Asking “Do you feel like crying helps?” might come across as judgmental or dismissive.
Choice D rationale
Asking “Would you like to be alone?” might make the patient feel isolated or abandoned.
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