A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?

Provide the client a sip of warm water and wait 5 min before measuring his oral temperature.

Wait 30 min and return to measure the client's oral temperature.

Proceed to measure the client's oral temperature.

Document the inability to obtain an accurate reading of the client's oral temperature.

Answer and Explanation

The Correct Answer is B

A. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature:
This does not reliably normalize oral temperature and can still affect the accuracy.

B. Wait 30 min and return to measure the client's oral temperature:
Eating or drinking cold or hot substances can alter the oral temperature reading. Waiting 15–30 minutes allows for an accurate measurement.

C. Proceed to measure the client’s oral temperature:
This can result in an inaccurate (falsely low) reading due to recent ice chips.

D. Document the inability to obtain an accurate reading of the client’s oral temperature:
This step would be appropriate only if the nurse was unable to return or use an alternative method, which is not the case here.

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Correct Answer is C

Explanation

A. Decrease the temperature in the client’s room:
This would worsen hypothermia. The room should be warm.

B. Place a cooling fan near the client:
Cooling is used for fevers, not hypothermia.

C. Place a warming blanket over the client:
This is a first-line intervention for mild hypothermia. It helps raise the core temperature.

D. Request a prescription for an antipyretic medication:
Antipyretics are used to reduce fever, not to treat hypothermia.

A. Cover the wound with a sterile normal saline soaked dressing. B. Apply an abdominal binder to the wound area. C. Assure the client that this is an expected occurrence after surgery. D. Turn the client onto her side.

Correct Answer is A

Explanation

A. Cover the wound with a sterile normal saline soaked dressing:
This keeps the exposed organs moist and reduces infection risk until surgical intervention.

B. Apply an abdominal binder to the wound area:
This can increase pressure and cause further damage to exposed organs.

C. Assure the client that this is an expected occurrence after surgery:
Evisceration is a surgical emergency, not expected.

D. Turn the client onto her side:
The client should be placed in a low Fowler’s position with knees bent to reduce abdominal strain-not on the side.

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