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

Choice A reason:

Proceeding to measure the oral temperature immediately after the client has consumed ice chips is incorrect. The cold substance can lower the temperature reading, leading to inaccurate results. The oral temperature measurement would not reflect the client's true body temperature.

Choice B reason:

Documenting that the temperature was not measured is not a practical approach to this situation. While it records the inability to take a measurement, it does not address the need to obtain an accurate temperature reading after an appropriate waiting period.

Choice C reason:

Providing warm water and then measuring the temperature after 5 minutes is not advisable. This method can cause a rebound effect, where the warm water temporarily raises the oral temperature, again leading to an inaccurate reading. It also does not provide a sufficient waiting period for the mouth to return to its baseline temperature.

Choice D reason:

Waiting 30 minutes before remeasuring the oral temperature is the best practice. This period allows the oral cavity to return to its normal temperature, ensuring that the reading is accurate and reflective of the client's true body temperature. It avoids the influence of recent ingestion of cold substances.

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Correct Answer is A

Explanation

Choice A reason: This is the correct answer. A black ulcer typically indicates necrotic tissue, which needs to be debrided to promote healing and prevent infection. Debridement involves removing dead tissue to allow healthy tissue to grow and reduce the risk of complications.

Choice B reason: Managing drainage from the wound is essential, but it is not the next immediate step when dealing with necrotic tissue. Proper drainage management occurs after debridement to maintain a clean wound environment and promote healing.

Choice C reason: Documenting the wound is crucial for tracking progress and treatment outcomes. However, it is not the immediate next step in managing a black, necrotic ulcer. Active intervention, such as debridement, is prioritized to address the underlying issue.

Choice D reason: Monitoring the wound is an ongoing process throughout treatment, but it does not address the immediate need for debridement of necrotic tissue. Regular monitoring follows initial interventions to ensure the wound is healing properly.

A. antiplatelet aggregate B. analgesic C. antipyretic D. anti-inflammatory

Correct Answer is A

Explanation

Choice A reason: This is the correct answer. Aspirin at a low dose (e.g., 325 mg) is commonly prescribed for its antiplatelet effects, which help prevent the formation of blood clots. This action reduces the risk of another myocardial infarction by keeping the blood flowing smoothly through the arteries.

Choice B reason: Aspirin does have analgesic properties, making it effective for pain relief. However, the primary reason for prescribing it post-myocardial infarction is its ability to prevent platelet aggregation and reduce the risk of further cardiac events.

Choice C reason: Aspirin can also act as an antipyretic to reduce fever. In the context of myocardial infarction, this property is not the primary reason for its prescription. The focus is on its cardiovascular protective effects through antiplatelet activity.

Choice D reason: Aspirin has anti-inflammatory effects, which are beneficial in various conditions. However, post-myocardial infarction, its main benefit is reducing the risk of clot formation through antiplatelet aggregation rather than its anti-inflammatory properties.

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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?

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