A nurse is measuring an adult client's tympanic temperature. Which of the following actions should the nurse take?
Use a cotton-tipped applicator to remove cerumen.
Insert the probe snugly into the ear canal and press scan.
Pull the pinna downward and backward.
Hold the probe flat against the forehead and press scan.
The Correct Answer is B
A. Use a cotton-tipped applicator to remove cerumen:
Inserting objects like cotton-tipped swabs into the ear canal is unsafe and can cause damage; not recommended for clearing earwax before temperature measurement.
B. Insert the probe snugly into the ear canal and press scan:
This is the correct method to ensure an accurate tympanic temperature reading.
C. Pull the pinna downward and backward:
This is correct for children under 3 years, not for adults.
D. Hold the probe flat against the forehead and press scan:
This technique is for a temporal artery thermometer, not tympanic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Elevate the client’s arm above the level of the heart:
This may falsely lower the reading. The arm should be at heart level.
B. Align the artery indicator on the BP cuff with the client’s brachial artery:
Correct alignment ensures accurate readings. Most cuffs have an arrow or line that must align with the brachial artery.
C. Place the BP cuff 5 cm (2 in) above the client’s antecubital space:
The cuff should be placed about 2.5 cm (1 inch) above the antecubital space-not 5 cm.
D. Select a cuff that covers 50% of the client’s upper arm:
The correct cuff should cover at least 80% of the arm’s circumference, not 50%, for accurate readings.
Correct Answer is A
Explanation
A. Place a gauze pad around the drain:
Penrose drains are open and passive. A gauze pad absorbs drainage and prevents skin irritation or maceration around the site.
B. Connect the drain to continuous low-pressure suction:
Penrose drains are not connected to suction. They allow drainage to passively exit the wound.
C. Clean the skin near the drain in a circular motion from the outside to the inside:
The correct method is to clean from the drain outward, to prevent contaminating the site.
D. Empty the drainage device when it is half full:
Penrose drains do not have a collection device to empty; instead, drainage is absorbed into gauze.
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