A nurse is reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)
A client who is drinking Ice water
A client who had recent oral surgery
A client who breaths through the mouth
A client who has hemorrhoids
A client who has a coagulation disorder
Correct Answer : D,E
A. If a client has just consumed ice water, it can lower the oral temperature and lead to inaccurate readings. It's generally recommended to wait at least 15-30 minutes after eating or drinking before taking an oral temperature.
B. A client who has had oral surgery may have swelling, pain, or open wounds, which could make taking an oral temperature uncomfortable and could also lead to inaccurate results. Alternative sites, such as axillary or tympanic, might be preferred.
C. Clients who primarily breathe through their mouth may have a lower oral temperature reading due to airflow affecting the measurement. Additionally, mouth breathing can lead to inaccuracies in the reading.
D. While hemorrhoids themselves do not affect the ability to take an oral temperature, this client is suitable for oral temperature measurement since it does not interfere with the method.
E. A client with a coagulation disorder can typically have their oral temperature taken. There are no contraindications to taking an oral temperature in this case, as long as the client does not have any other conditions affecting their ability to do so.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The reservoir is the natural habitat of the infectious agent where it lives, grows, and multiplies. In the case of hepatitis A, the reservoir could be contaminated food, water, or infected individuals. The mouth is not the reservoir; rather, it is a route through which the infection enters the body.
B. The infectious agent is the pathogen (bacteria, virus, or other microorganisms) that causes the disease. For hepatitis A, the infectious agent is the hepatitis A virus itself. The mouth is not the infectious agent; it's the entry point for the virus.
C. A susceptible host is an individual who is at risk of infection due to factors such as weakened immunity, age, or underlying health conditions. The client with hepatitis A is a susceptible host, but the mouth is not categorized as such.
D. The portal of entry is the way an infectious agent enters a susceptible host. In the case of hepatitis A acquired through contaminated food, the mouth serves as the portal of entry. The virus enters the body when the contaminated food is ingested.
Correct Answer is A
Explanation
A. Indirect contact transmission occurs when a person touches a contaminated object or surface (fomite) and then touches their body, which can lead to infection. In this case, the client acquired the infection by touching a contaminated towel, making this an example of indirect contact transmission.
B. A vector is an organism, often an insect, that transmits pathogens from one host to another. Examples include mosquitoes transmitting malaria or ticks transmitting Lyme disease. Staphylococcus aureus does not involve a vector in its transmission; thus, this option is incorrect.
C. Droplet transmission occurs when respiratory droplets carrying infectious pathogens are expelled from an infected person and enter another person’s mucous membranes (e.g., nose, mouth, eyes) during actions like coughing or sneezing.
D. Airborne transmission involves pathogens that are carried in the air over long distances and can be inhaled by individuals. Diseases such as tuberculosis are transmitted this way. However, Staphylococcus aureus infection through touching a towel does not involve airborne transmission.
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