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 B

Explanation

A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.

B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.

C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.

D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.

A. Assess the pedal pulses with a Doppler device B. Assess the pedal pulses for a full minute C. Assess the apical pulse with a Doppler device D. Assess the apical pulse for a full minute

Correct Answer is D

Explanation

A. Assessing the pedal pulses with a Doppler device is not necessary in this situation; the focus should be on the apical pulse due to the irregularity noted in the radial pulse.

B. Assessing the pedal pulses for a full minute does not address the irregularity of the radial pulse and is not the priority.

C. While assessing the apical pulse is appropriate, using a Doppler device is not required unless there are difficulties in obtaining the pulse normally.

D. Assessing the apical pulse for a full minute is the correct action because it provides a more accurate reflection of the heart's rhythm and rate, especially when there is an irregular radial pulse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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