A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain.

Which of the following conditions in the client's history should the nurse identify as a contraindication?

The correct answer is choice C. The AP pulls the pinna up and back.

Choice A rationale:

Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.

Choice B rationale:

Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.

Choice C rationale:

Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.

Choice D rationale:

Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.

The correct answer is choice b. Performing indwelling urinary catheter care.

Choice A rationale:

Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).

Choice B rationale:

Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.

Choice C rationale:

Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.

Choice D rationale:

Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.