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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Used razors should never be disposed of in regular wastebaskets as they pose a significant risk for puncture injuries. Instead, they should be placed in a designated sharps container to prevent accidental cuts or injuries to anyone handling the waste.
B. The practice of using two hands to recap a needle is not recommended because it increases the risk of a needlestick injury. Instead, nurses should use a one-handed technique or a safety device designed for recapping needles to minimize the risk of injury.
C. Needles should not be broken off from syringes before disposal, as this can create sharp edges that can puncture the skin and lead to injuries. Instead, syringes with needles should be disposed of intact in a designated sharps container.
D. Sharps containers should be replaced when they are full to ensure safe disposal of needles and other sharp instruments. Overfilled containers can pose a risk of needlestick injuries and may not allow for proper disposal of new sharps.

A. A client is scheduled to receive an influenza vaccination B. A client who has a family history of breast cancer is scheduled for a mammogram. C. A client who has heart failure is scheduled for an echocardiogram. D. A client who is asymptomatic is not scheduled for a series of tests.

Correct Answer is B

Explanation

A. This is an example of primary prevention. Vaccinations are aimed at preventing illness before it occurs by building immunity, making this an action focused on health promotion and disease prevention.
B. This is an example of secondary prevention. Mammograms are screening tests used to detect breast cancer early in asymptomatic individuals, allowing for early intervention and treatment. This level of prevention focuses on early detection and intervention.
C. This is an example of tertiary prevention. An echocardiogram is used to assess and manage an existing health condition (heart failure) rather than to prevent the onset of a disease. This level of prevention focuses on managing and minimizing the effects of established diseases.
D. This does not represent a level of prevention but rather indicates a decision to not pursue further diagnostic testing based on the absence of symptoms. This choice aligns more with the absence of active preventive measures rather than a defined level of prevention.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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