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: 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.

A. Check the client’s skin every 8 hours for signs of breakdown. B. Clean the client’s skin and perineum with hot water after each episode of incontinence. C. Apply a moisture barrier ointment to the client’s skin. D. Request a prescription for the insertion of an indwelling urinary catheter.

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.

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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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