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 A
Explanation
Choice A rationale
Spending time with the patient is a therapeutic nursing approach when caring for a patient hospitalized for the treatment of severe depression. This approach shows the patient that they
are not alone and that their feelings are important. It can help build trust and rapport, which are essential for effective therapeutic communication and intervention.
Choice B rationale
Offering the patient choices of activities can be beneficial as it can provide a sense of control and improve mood. However, this approach should be used judiciously as the patient’s energy levels and interest in activities may be low due to depression.
Choice C rationale
Establishing a therapeutic relationship with the patient is an important aspect of care. However, this is a broad approach and involves more than just spending time with the patient. It includes building trust, maintaining confidentiality, and providing empathetic and nonjudgmental care.
Choice D rationale
Exploring the truth of the patient’s statements can be part of cognitive behavioral therapy (CBT), a common treatment for depression. However, this is usually done by a trained therapist and not by a nurse providing general care.
Correct Answer is D
Explanation
When caring for a patient who practices Islam, the nurse should request a meal tray without pork. Dietary laws in Islam, known as halal, prohibit the consumption of pork.
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