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 minutes, and measure the temperature.

Wait 30 minutes 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 eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.

B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.

C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.

D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.

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Correct Answer is C

Explanation

A: Checking the client’s skin every 8 hours is not frequent enough to prevent skin breakdown in a client with urinary incontinence. More frequent checks are necessary to identify and address any issues promptly.

B: Cleaning the client’s skin and perineum with hot water can cause skin irritation and dryness. It is better to use lukewarm water and gentle cleansers to maintain skin integrity.

C: Applying a moisture barrier ointment to the client’s skin is an effective way to prevent skin breakdown. The ointment creates a protective barrier that helps keep moisture away from the skin, reducing the risk of irritation and breakdown.

D: Requesting a prescription for the insertion of an indwelling urinary catheter is not the best first-line intervention for preventing skin breakdown. Catheters carry a risk of infection and should be used only when absolutely necessary.

A. Obtain a chest x-ray. B. Raise the head of the bed. C. Administer prescribed analgesic. D. Administer oxygen at 2 L/min.

Correct Answer is B

Explanation

A: Obtaining a chest x-ray is important for diagnosing potential complications but is not the immediate first action to improve oxygen saturation.

B: Raising the head of the bed helps improve lung expansion and oxygenation. It is a quick and effective first step to increase oxygen saturation.

C: Administering a prescribed analgesic can help with pain management but does not directly address the low oxygen saturation.

D: Administering oxygen at 2 L/min is important but should follow the initial step of raising the head of the bed to optimize breathing.

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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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