A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Proceed to measure the oral temperature.

Document that the nurse was unable to measure the client's temperature.

Provide the client a sip of warm water, wait 5 min, and measure the temperature.

Wait 30 min and return to measure the oral temperature.

Answer and Explanation

The Correct Answer is D

A. Proceeding to measure the oral temperature immediately after the client has consumed ice chips can lead to an inaccurate reading due to the cooling effect of the ice.

B. Documenting that the nurse was unable to measure the client's temperature is unnecessary; it is possible to obtain an accurate measurement after a suitable waiting period.

C. Providing a sip of warm water will not resolve the issue of the ice chips affecting the temperature reading, as the nurse should still wait a longer period for accuracy.

D. Waiting 30 minutes after the client has consumed ice chips is the best practice, as it allows sufficient time for the oral cavity to return to a baseline temperature for an accurate measurement.

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Correct Answer is A

Explanation

A. Determining the location of the pain is the first step, as it helps the nurse understand the nature and source of the pain, guiding appropriate intervention and medication administration.

B. Repositioning the client may provide comfort but should follow an assessment of the pain to ensure targeted interventions.

C. Administering the medication without understanding the specifics of the pain is inappropriate, as it may not adequately address the client’s needs.

D. Reviewing the effects of the pain medication is important but should occur after assessing the pain to ensure the correct medication is administered based on the client’s specific situation.

A. Observe the client before taking further action. B. Perform the Heimlich maneuver C. Slap the client on the back several times. D. Assist the client to the floor and begin mouth-to-mouth resuscitation.

Correct Answer is B

Explanation

A. Observing the client is inappropriate as they are demonstrating signs of choking and require immediate intervention.

B. Performing the Heimlich maneuver is appropriate as the guest is unable to talk, which indicates a potential airway obstruction that needs to be relieved promptly.

C. Slapping the client on the back may not be effective and could worsen the obstruction, especially since they are grasping their throat.

D. Assisting the client to the floor and beginning mouth-to-mouth resuscitation is not appropriate in this situation, as the priority is to clear the obstruction, not to provide rescue breaths.

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