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 C
Explanation
Choice A Reason:
Documenting the event in the client's progress notes is not the immediate action to take. While it's important to document significant events, the priority is to stop the unauthorized disclosure of the client's information and address the privacy breach.
Choice B Reason:
Informing the client of the APs' actions is not the initial step to take. The priority is to address the issue and stop the conversation to prevent further disclosure of confidential information. However, the client may need to be informed about the breach of privacy as part of the organization's protocol.
Choice C Reason:
Telling the APs to stop the conversation is correct. Overhearing discussions about a client's personal information by unauthorized personnel is a breach of patient privacy and confidentiality, which is a serious violation of healthcare ethics and regulations. Therefore, the nurse should address the situation immediately by telling the assistive personnel (APs) to stop the conversation. Here's why each option is appropriate or not:
Choice D Reason:
Submitting an incident report to the risk manager is an appropriate step to take but should not be the first action. The immediate concern is to address the situation and stop the unauthorized discussion. After that, the incident should be documented and reported according to the facility's policies and procedures.
Correct Answer is C
Explanation
Explanation:
Sponge baths are recommended until the umbilical cord stump falls off, which typically occurs within the first two weeks of life. After that, the baby can be immersed in water for a regular bath.
Using talcum powder is not recommended as it can be harmful to the baby's respiratory system if inhaled. Mild, pH-balanced soap should be used instead of alkaline soap to avoid irritating the baby's delicate skin.
The bathwater temperature should be around 98 degrees Fahrenheit and not hoter than 100 degrees Fahrenheit to prevent burns.
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