A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?
The AP inserts the probe with a straight, forward motion.
The AP positions the client facing her.
The AP pulls the pinna up and back.
The AP points the probe posteriorly.
The Correct Answer is C
Choice A Reason:
Inserting the probe with a straight, forward motion is not correct because the ear canal is curved, and this technique could lead to inaccurate readings or discomfort.
Choice B Reason:
The AP positions the client facing her. The position of the client's face is not relevant to taking a tympanic temperature. The client can face any direction during the procedure.
Choice C Reason:
Pulling the pinna up and back straightens the ear canal in adults, allowing for a more accurate reading when taking a tympanic temperature.
Choice D Reason:
Pointing the probe posteriorly is incorrect as the probe should be pointed towards the tympanic membrane, which usually requires slight angling to align with the ear canal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I will notify my provider if my baby sleeps more than 10 hours per day." This statement is not in line with normal newborn sleep patterns. Newborns typically sleep for longer durations and wake up for feedings. It's essential for parents to follow their provider's guidance on feeding and sleep schedules.
Choice B Reason:
"I will place my baby on his back for sleeping." This statement indicates an understanding of safe sleep practices for newborns. Placing a baby on their back for sleep is recommended to reduce the risk of sudden infant death syndrome (SIDS).
Choice C Reason:
"I will change my baby's diaper every 4 hours." While it's important to change a baby's diaper regularly, the frequency of diaper changes may vary depending on the baby's needs. Diapers should be changed when wet or soiled, not necessarily on a strict time schedule.
Choice D Reason:
"I will limit my baby's feedings so he does not become overweight." It is not advisable to limit a newborn's feedings for concerns about becoming overweight. Newborns need to feed frequently to meet their nutritional needs and support healthy growth and development. Parents should follow their healthcare provider's guidance on feeding and monitor the baby's growth and weight appropriately.
Correct Answer is A
Explanation
a. Apply pressure to the lacrimal punctum after administering the drops.
When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side effects.
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