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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Irrigate the wound until the solution that is draining is clear:
Continue irrigation until visible debris and drainage are removed, and the fluid runs clear, indicating cleanliness.
B. Hold the tip of the syringe inside of the wound while irrigating:
This can cause tissue trauma. The syringe should be held just above the wound.
C. Flush the wound from the most contaminated area to the cleanest area:
Always cleanse from the cleanest to the most contaminated area to prevent spread of microorganisms.
D. Chill the irrigant prior to the procedure:
Room temperature or warmed solutions are preferred to prevent lowering the tissue temperature, which can delay healing.
Correct Answer is A
Explanation
A. Place the client’s arm above the level of the heart:
The arm should be at heart level. Positioning it above the heart can lead to a falsely low BP reading.
B. Check the instrument gauge to ensure the reading starts at zero:
This ensures that the starting point is accurate, avoiding false readings.
C. Center the cuff bladder over the brachial artery:
Correct placement of the cuff ensures accurate compression of the artery during measurement.
D. Wrap the blood pressure cuff snugly around the arm:
The cuff should be snug but not tight, which helps in getting an accurate reading.
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