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 C
Explanation
A. Massage reddened areas during dressing changes:
Massaging reddened or compromised skin can worsen tissue damage and increase the risk of further injury.
B. Apply a heat lamp twice a day:
Heat lamps are not recommended and may dry out the wound bed or burn healing tissue.
C. Cleanse with 0.9% sodium chloride irrigation:
Normal saline is gentle and effective for cleaning granulating tissue without causing damage or cytotoxic effects.
D. Cleanse with povidone-iodine solution:
Povidone-iodine is cytotoxic and can impair wound healing, especially to new granulating tissue.
Correct Answer is A
Explanation
A. Carotid:
Palpating both carotid arteries at the same time can occlude blood flow to the brain, potentially leading to fainting or loss of consciousness.
B. Femoral:
Femoral pulses can be palpated bilaterally without risk to cerebral circulation.
C. Popliteal:
Popliteal pulses are in the legs and can be checked simultaneously.
D. Brachial:
Brachial pulses are safe to assess bilaterally and often checked when comparing arm circulation.
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