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 A
Explanation
Choice A rationale:
"I should have my baby latch on to my nipple and areola during feeding." Rationale: This is the correct statement and indicates an understanding of breastfeeding. Proper latch involves the baby taking both the nipple and a portion of the areola into their mouth. This ensures effective milk transfer and prevents nipple pain and damage.
Choice B rationale:
"I should not wake my baby during the night to breastfeed." Rationale: While it is generally recommended to let a newborn sleep for longer stretches at night, it's essential to ensure the baby feeds frequently, especially in the early days. Waking the baby for feedings, at least every 2-3 hours, is important to establish a good milk supply and ensure the baby's nutritional needs are met.
Choice C rationale:
"My baby should breastfeed 5 to 10 minutes on each breast." Rationale: This statement is not entirely accurate. The duration of breastfeeding can vary from baby to baby. It's essential to allow the baby to feed as long as they want on the first breast, ensuring they get the hindmilk, which is rich in fat and essential for growth. The baby may switch to the other breast when they are ready.
Choice D rationale:
"I should keep my baby on a strict feeding schedule." Rationale: This statement is not correct. Breastfeeding is demand-driven, and it's important to feed the baby when they show hunger cues, which may not always align with a strict schedule. Feeding on demand helps ensure the baby receives enough nourishment and promotes milk supply.
Correct Answer is A
Explanation
Choice A rationale:
Monitoring for muscle paralysis is crucial in botulism poisoning because it is a characteristic symptom of the condition. Botulinum toxin causes muscle weakness and paralysis, which can lead to respiratory distress. Monitoring for these symptoms allows for timely intervention.
Choice B rationale:
Placing the client in contact isolation is not a priority in botulism poisoning. Botulism is not typically transmitted from person to person, so isolation is not necessary. The focus should be on monitoring and supportive care.
Choice C rationale:
Checking for increased salivation is important because excessive salivation is a symptom of botulism poisoning. However, monitoring for muscle paralysis is more critical as it can lead to respiratory compromise.
Choice D rationale:
Administering clindamycin hydrochloride is not a standard treatment for botulism poisoning. The primary treatment involves supportive care and, in some cases, the administration of antitoxin if available.
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