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
The correct answer is choice b. Reduced fat in the stools.
Choice A rationale:
Decreased sodium excretion is not a therapeutic effect of pancrelipase. Pancrelipase is an enzyme replacement therapy that helps in the digestion of fats, proteins, and carbohydrates, but it does not affect sodium excretion.
Choice B rationale:
Reduced fat in the stools is the correct answer. Pancrelipase helps in the digestion of fats, which reduces the amount of fat excreted in the stools. This is particularly important for patients with cystic fibrosis, who often have pancreatic insufficiency leading to malabsorption of fats.
Choice C rationale:
Improved respiratory function is not a direct therapeutic effect of pancrelipase. While better nutrition and absorption can indirectly support overall health, including respiratory function, pancrelipase specifically targets digestive enzyme insufficiency.
Choice D rationale:
Improved absorption of vitamins B and C is not the primary therapeutic effect of pancrelipase. Pancrelipase aids in the absorption of fat-soluble vitamins (A, D, E, and K) rather than water-soluble vitamins like B and C.
Correct Answer is D
Explanation
The correct answer is: d. Location of the identification tag on the client’s body.
Choice A reason: The cause of the client’s death is determined by a physician or a medical examiner and is not typically documented by nurses in postmortem documentation. The cause of death is a medical determination that involves a complex process, including examination and possibly an autopsy.
Choice B reason: The last set of the client’s vital signs is relevant prior to death and is part of the end-of-life documentation. However, once the client has passed away, recording vital signs is no longer applicable and is not included in postmortem documentation.
Choice C reason: A copy of the client’s advance directives is an important document that outlines the client’s wishes regarding medical treatment and interventions. While it is crucial before the client’s death, it does not need to be included in postmortem documentation, as it serves no purpose after death.
Choice D reason: The location of the identification tag on the client’s body is a critical piece of information that must be included in postmortem documentation. This ensures that the body is correctly identified throughout the postmortem process, including during transfer to a mortuary or funeral home.
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