A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?

Insert the tip of the thermometer 5 cm (2 in) into the rectum.

Place the child in prone position.

Stabilize the thermometer at the distal end.

Direct the tip of the thermometer toward the spine during insertion.

Answer and Explanation

The Correct Answer is C

A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. The correct insertion depth is 2.5 cm (1 inch) for toddlers to avoid rectal injury.
B. Place the child in prone position. The child should be placed in the side-lying or supine position with legs flexed.
C. Stabilize the thermometer at the distal end. Stabilizing the thermometer ensures it remains in position during the procedure, minimizing risk of injury.
D. Direct the tip of the thermometer toward the spine during insertion. The thermometer should be directed toward the umbilicus to follow the natural rectal curve.

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Correct Answer is ["D","E"]

Explanation

A. If the baby vomits, do not administer another dose without consulting the provider to avoid overdosing.
B. There is no expected reduction in urination with GER medications. If decreased urination occurs, it may indicate dehydration or another issue.
C. The baby should not be positioned flat when administering medication to avoid choking or aspiration.
D. Avoid diluting medication in a formula bottle, as the infant may not finish the bottle, leading to incomplete dosing.
E. Administering medication with a syringe ensures accurate dosing and avoids wasting the medicine.

A. A 15-year-old client who requires an open reduction of a fracture. B. A 6-month-old infant requiring IV antibiotics. C. 14-year-old client seeking prenatal care. D. A 5-year-old child requiring a chest x-ray.

Correct Answer is A

Explanation

A. A 15-year-old client who requires an open reduction of a fracture. Minors generally require parental or guardian consent for surgical procedures unless emancipated.
B. A 6-month-old infant requiring IV antibiotics. Informed consent from the guardian is required for medical interventions like IV antibiotics in infants.
C. A 14-year-old client seeking prenatal care. Pregnant minors in many jurisdictions are allowed to consent for their own prenatal care without a guardian's approval.
D. A 5-year-old child requiring a chest x-ray. While routine x-rays require parental consent, in an emergency, consent may not be necessary if immediate care is required to stabilize the child.

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A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["D","E"]

Explanation

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Correct Answer is A

Explanation

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