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 C
Explanation
A. Full thickness skin loss with visible bone:
This describes a stage 4 pressure injury.
B. Full thickness skin loss with visible adipose tissue:
This describes a stage 3 pressure injury.
C. Partial-thickness skin loss with red tissue in wound bed:
Stage 2 pressure injuries involve partial-thickness skin loss, sometimes with a pink or red wound bed and may include blistering.
D. Intact skin with localized erythema:
This describes a stage 1 pressure injury.
Correct Answer is A
Explanation
A. Cleanse the wound with sterile saline:
This removes surface contaminants, ensuring the specimen reflects organisms within the wound, not contaminants from the skin.
B. Don sterile gloves:
While sterile technique is important, cleansing the wound must occur before donning sterile gloves to prevent contaminating the site.
C. Swab the wound bed with a sterile cotton-tipped swab:
This is done after cleansing the wound to collect an accurate sample.
D. Place the collection tube in a specimen bag:
This is the final step after the specimen is collected.
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