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. Hold her breath for at least 10 seconds. Diaphragmatic breathing focuses on slow, deep breaths to promote lung expansion and oxygenation. Holding the breath is not part of this technique and may increase discomfort.

B. Place her hands on the sides of her rib cage. While hand placement is encouraged, the correct position is on the abdomen (below the rib cage), not the sides. This helps the client feel the diaphragm expanding.

C. Exhale forcefully through the nose. Exhalation should be slow and controlled through the mouth, not forceful through the nose, to prevent airway irritation.

D. Inhale slowly and evenly through her nose. The correct technique for diaphragmatic breathing is to inhale deeply through the nose while the abdomen expands. This promotes lung expansion and prevents atelectasis postoperatively.

A. Aortic and Mitral B. Mitral and Pulmonic C. Mitral and Tricuspid D. Aortic and Pulmonic

Correct Answer is D

Explanation

A. Aortic and Mitral: The mitral valve is associated with the S1 sound, not S2. S2 occurs when the semilunar valves (aortic and pulmonic) close.

B. Mitral and Pulmonic: The mitral valve closure is heard in S1, while the pulmonic valve closure is part of S2. However, the mitral valve is not involved in S2.

C. Mitral and Tricuspid: The mitral and tricuspid valves close during S1, not S2. These valves are atrioventricular (AV) valves, not semilunar valves.

D. Aortic and Pulmonic: The second heart sound (S2) is produced by the closure of the aortic and pulmonic valves at the beginning of diastole. This marks the end of systole.

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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

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