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 straightforward 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
The correct answer is choice C. The AP pulls the pinna up and back.
Choice A rationale:
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
Choice B rationale:
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
Choice C rationale:
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
Choice D rationale:
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Urinary specimens collected from the bag may be contaminated and do not provide a reliable sample. A sterile specimen should be collected from the catheter port if needed.
B.In male patients secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension.
C.Guidelines recommend that the urinary drainage bag be kept below the level of the bladder, typically lower than the waist, to ensure proper urine flow and prevent reflux.
D.Coiling the tubing can impede proper drainage, leading to potential complications like urinary retention and infection.
Correct Answer is B
Explanation
B. “I should discuss this document with my family after I sign it.”It is important for clients to discuss their advance directives with their family members to ensure that their wishes are understood and respected. This helps prevent confusion and ensures that family members are aware of the client’s preferences for end-of-life care.
Incorrect Options:
A. “I am not allowed to change my mind once I sign this document.”Clients can change or revoke their advance directives at any time as long as they are competent to do so.
C. “My partner needs to be present when I sign this document.”While it is a good idea to have a witness, it is not necessary for the partner to be present. The requirements for witnesses vary by jurisdiction.
D. “An attorney will need to notarize this document for it to be valid.”Not all advance directives require notarization. The requirements vary by state or country, and some may only require witnesses.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.