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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A: Using a microwave for cooking is generally safe for older adults with decreased vision. Microwaves are user-friendly and reduce the risk of burns or fires compared to stovetops. However, it is important to ensure that the microwave is at an accessible height and that the user can read the controls or has them memorized.
B: Handrails in the bathroom are a safety feature, not a risk. They provide support and stability, reducing the likelihood of falls, which is crucial for individuals with decreased vision. Properly installed handrails can significantly enhance bathroom safety.
C: Electrical cords placed along the walls are typically not a safety risk if they are secured properly and do not create tripping hazards. It is important to ensure that cords are not loose or crossing walkways where they could cause falls.
D: Scatter rugs in the kitchen are a significant safety risk for older adults with decreased vision. These rugs can easily cause tripping and falling, especially if they are not secured with non-slip backing. Removing scatter rugs or securing them properly is essential to prevent accidents.
Correct Answer is D
Explanation
A: Administering the medication and monitoring the patient frequently is not appropriate because phenytoin is not indicated for pain management.
B: Refusing to give the medication and notifying the nurse supervisor is a step in the right direction, but the nurse should also seek clarification from the health care provider.
C: Giving the patient hydromorphone without clarification is not appropriate. The nurse must verify the order with the health care provider.
D: Calling the health care provider to clarify the order is the correct action. This ensures that the correct medication is administered as intended.
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