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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Explain the procedure to the child. Explaining procedures in an age-appropriate manner helps reduce anxiety and increases cooperation. A 3-year-old can understand simple instructions, so explaining what will happen can help them remain calm.
B. Choose the cuff that says "Child" instead of "Infant." Blood pressure cuffs should be appropriately sized for accurate readings. A cuff that is too small can result in falsely high readings, while a cuff that is too large can produce falsely low readings.
C. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. The bell of the stethoscope is best for detecting low-pitched sounds, including Korotkoff sounds.
D. Obtain the reading before the child has a chance to settle down. A child who is upset, crying, or anxious may have an elevated blood pressure reading due to stress. It is best to allow the child to calm down before obtaining an accurate measurement.
Correct Answer is D
Explanation
A. You will need to use a stethoscope properly. A portable electronic blood pressure device is automatic and does not require the use of a stethoscope. The device detects oscillations in arterial pressure to provide a reading.
B. You can move your arm during the reading. Movement during the reading can interfere with accuracy and produce incorrect results. The patient should keep the arm still and at heart level.
C. You can apply the cuff in any manner. The cuff must be applied correctly—snug but not too tight, with the lower edge about 1 inch above the antecubital fossa, and the bladder of the cuff positioned over the artery—to ensure accurate readings.
D. You will need to recalibrate the machine. Electronic blood pressure devices require periodic recalibration to maintain accuracy. The patient should follow the manufacturer’s guidelines for recalibration and compare readings with a manual blood pressure check at clinic visits.
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