A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Place the tip of the thermometer under the center of the infant's axilla

Pull the pinna of the Infant's ear forward before inserting the probe.

Insert the oral thermometer in front of the infant's tongue.

Insert the probe 3.8 cm (15 in into the infant's rectum

Answer and Explanation

The Correct Answer is A

A. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.

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Correct Answer is B

Explanation

A. Open the outermost flap of the sterile kit toward the body. The outermost flap should always be opened away from the body first to prevent contamination of the sterile field by leaning over it. This helps maintain sterility by minimizing the risk of contact.
B. Place the cap from the solution sterile side up on a clean surface. Placing the cap sterile side up prevents the sterile inner surface from touching the contaminated surface and helps maintain aseptic technique during solution use.
C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field. The outer 2.5 cm (1 inch) border of a sterile field is considered contaminated. Placing items too close to the edge increases the risk of contamination and compromises the field's sterility.
D. Set up the sterile field 5 cm (2 in) below waist level. Any sterile item held or placed below waist level is considered contaminated. The sterile field must always be maintained above waist level to preserve asepsis.

A. Urticaria B. Wheezing C. Muscle rigidity D. Hypercapnia E. Tachycardia

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B,C"}}

Explanation

Urticaria: Urticaria (hives) is a hallmark sign of an allergic reaction, particularly latex allergy, and typically appears quickly following exposure to allergens. It is not seen in malignant hyperthermia or hypovolemic shock.
Wheezing: Wheezing can occur in latex allergy due to bronchospasm or airway edema. While respiratory compromise may happen in malignant hyperthermia, it is typically due to muscle breakdown and CO2 retention, not bronchospasm. Wheezing is not expected in hypovolemic shock.
Muscle rigidity: Generalized rigidity, especially of the jaw (masseter spasm), is a key early sign of malignant hyperthermia, a life-threatening reaction to certain anesthetics. It is not a symptom of latex allergy or hypovolemic shock.
Hypercapnia: An elevated PaCO₂ is an early, sensitive marker of malignant hyperthermia, resulting from increased CO₂ production due to sustained muscle contraction. This does not occur in latex allergy or hypovolemic shock.
Tachycardia: Elevated heart rate can be seen in all three conditions: in malignant hyperthermia due to increased metabolic demand, in latex allergy due to anaphylactic reaction, and in hypovolemic shock as a compensatory response to fluid loss.

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A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Correct Answer is B

Explanation

A nurse is caring for a client who is postoperative following a right hip arthroplasty. For each assessment finding, click to specify if the finding is consistent with Malignant hyperthermia, Latex allergy, or Hypovolemic shock. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B,C"}}

Explanation

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