A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)

Rectal

Urinary Bladder

Temporal Artery

Esophagus

Pulmonary artery

Answer and Explanation

Correct Answer : A,B,D,E

A. Rectal: The rectal route provides a reliable measure of core body temperature because of its proximity to major blood vessels.

B. Urinary Bladder: A temperature-sensing urinary catheter can provide continuous monitoring of core temperature, especially in critical care settings.

C. Temporal Artery: While temporal artery thermometers are non-invasive and commonly used, they measure skin temperature, which is not a true core temperature.

D. Esophagus: Esophageal temperature monitoring is used in intubated patients and cardiac surgery patients to measure core temperature accurately.

E. Pulmonary Artery: A pulmonary artery catheter (Swan-Ganz catheter) directly measures blood temperature from the heart, making it the most accurate core temperature measurement.

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Correct Answer is D

Explanation

A. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV.

B. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I.

C. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.

D. Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II.

Correct Answer is ["1170"]

Explanation

Step 1: Convert cups and ounces to mL (1 cup = 240 mL, 1 oz = 30 mL):

Coffee: 1 cup = 240 mL
Orange juice: 4 oz × 30 mL = 120 mL
Water (first): 3 oz × 30 mL = 90 mL
Flavored gelatin: 1 cup = 240 mL
Tea: 1 cup = 240 mL
Broth: 5 oz × 30 mL = 150 mL
Water (second): 3 oz × 30 mL = 90 mL

Step 2: Add all the mL values together:
240 + 120 + 90 + 240 + 240 + 150 + 90 = 1,170 mL

Final Answer: 1,170 mL

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A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

Correct Answer is D

Explanation

Correct Answer is ["1170"]

Explanation

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