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
Related Questions
Correct Answer is D
Explanation
A: Hypotension is not an early sign of hypoxemia. It can occur in severe cases but is not typically an initial indicator.
B: Nausea is not a common sign of hypoxemia. It may occur due to other factors but is not directly related to low oxygen levels.
C: Dysphagia, or difficulty swallowing, is not a sign of hypoxemia. It is related to swallowing disorders rather than oxygen levels.
D: Confusion is an early sign of hypoxemia. Low oxygen levels can affect brain function, leading to confusion and other cognitive changes.
Correct Answer is C
Explanation
A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.
B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.
C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.
D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.
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