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
The correct answer is choiceb. Place the client in Trendelenburg position.
Choice A rationale:
Loosely wrapping the cord with petroleum gauze is not recommended.Instead, the cord should be wrapped with sterile saline-soaked gauze to prevent it from drying out and to minimize infection risk.
Choice B rationale:
Placing the client in Trendelenburg position helps to relieve pressure on the prolapsed cord by using gravity to shift the fetus away from the pelvis. This position helps to improve blood flow through the umbilical cord until delivery can be arranged.
Choice C rationale:
Evaluating uterine tone is not directly related to managing a prolapsed umbilical cord.The priority is to relieve pressure on the cord to prevent fetal hypoxia.
Choice D rationale:
Applying fundal pressure is contraindicated as it can increase pressure on the prolapsed cord, worsening the situation.
Correct Answer is C
Explanation
The correct answer is C.
Check the child for oral injuries. The rationale is that during a tonic-clonic seizure, the child may bite their tongue, cheek or lips and cause bleeding or damage to their oral tissues. The nurse should inspect the child's mouth for any injuries and provide appropriate care.
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