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 points the probe posteriorly.
The AP pulls the pinna up and back.
The AP positions the client facing her.
The Correct Answer is C
The correct answer is: c. The AP pulls the pinna up and back.
Choice A reason: The AP inserting the probe with a straight, forward motion is not the correct technique for tympanic temperature measurement. The ear canal does not run straight forward into the head; instead, it curves slightly. Inserting the probe straight forward could potentially damage the ear canal or eardrum and would not provide an accurate temperature reading.
Choice B reason: Pointing the probe posteriorly is also incorrect. The tympanic membrane is located at the end of the ear canal, and the probe should be directed towards it. However, the probe should be angled slightly downward and toward the jawline, not straight back, to align with the ear canal and ensure an accurate reading.
Choice C reason: Pulling the pinna up and back is the correct method for adults and children over one year old. This action straightens the ear canal, allowing the thermometer’s sensor to get a clear path to the tympanic membrane, which is necessary for an accurate temperature reading. For infants, the correct method is to pull the earlobe straight back.
Choice D reason: The AP positioning the client facing her does not directly relate to the technique of measuring tympanic temperature. While it may be necessary for the AP to see the client’s ear, it is not an indication of understanding the correct procedure for tympanic temperature measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Using iodine to disinfect cuts on the feet is not recommended for individuals with diabetes. Iodine can be harsh and may delay wound healing. It's better to clean cuts with mild soap and water and consult a healthcare professional for proper wound care.
Choice B rationale:
Wearing a clean pair of cotton socks each day is an excellent practice for someone with diabetes. Cotton socks can help absorb moisture and reduce the risk of fungal infections and pressure sores.
Choice C rationale:
Soaking feet in warm water every morning is not recommended for individuals with diabetes, as it can lead to skin drying and cracking. It's better to soak feet in lukewarm water occasionally, not daily, and to moisturize afterward.
Choice D rationale:
Attempting to remove ingrown toenails at home is not advisable for individuals with diabetes, as it can lead to infection and complications. Clients with diabetes should seek professional foot care for any foot issues, including ingrown toenails.
Correct Answer is D
Explanation
The Heelis not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The coccyx, or tailbone, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The Occiput, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
he breasts, particularly in female clients, can experience significant pressure when in the prone position. Using a small pillow can help to relieve this pressure and increase the client’s comfort.A small pillow can help support the client’s breasts and prevent them from being compressed or injured during the prone position1.The breasts are a sensitive area that can be affected by gravity, friction, or pressure2.A pillow can also help maintain proper body alignment and prevent hyperextension of the back
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