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
Performing passive range of motion exercises on the right leg in Buck’s traction may not be appropriate. These exercises involve moving the joint without the patient’s muscles doing the work, which could disrupt the traction.
Choice B rationale
Isometric exercises involve contracting the muscles without moving the joints. While these exercises can be beneficial for maintaining muscle strength, they may not promote mobility.
Choice C rationale
Performing active range-of-motion exercises on the left leg can help promote mobility. These exercises involve the patient moving the joint through its full range of motion, which can help maintain joint flexibility and muscle strength.
Choice D rationale
Log rolling the patient every 2 hours may not be appropriate for a patient in Buck’s traction. This technique involves turning the patient as a unit to prevent twisting and protect the spine, which could disrupt the traction.
Correct Answer is A
Explanation
Choice A rationale
Amoxicillin-clavulanate is a type of antibiotic that falls under the class of penicillin antibiotics. If a patient is allergic to penicillin, they should not take amoxicillin as it belongs to the penicillin class of antibiotics and must be avoided. Therefore, if a nurse is caring for a child who is allergic to penicillin, they should verify a prescription for amoxicillin-clavulanate with the provider.
Choice B rationale
Gentamicin is an aminoglycoside antibiotic, not a penicillin antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.
Choice C rationale
Erythromycin is a macrolide antibiotic, not a penicillin antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.
Choice D rationale
Amphotericin B is an antifungal medication, not an antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.
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