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. Left-sided heart failure: Left-sided heart failure causes pulmonary congestion leading to crackles, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up gasping for air).
B. Myocardial ischemia: Myocardial ischemia causes chest pain, shortness of breath, and fatigue, but it does not cause crackles in the lungs or fluid overload symptoms.
C. Right-sided heart failure: Right-sided heart failure results in systemic congestion (peripheral edema, weight gain, and jugular vein distention), not pulmonary symptoms like crackles.
D. Atrial fibrillation: Atrial fibrillation causes irregular heartbeats, palpitations, and fatigue, but it is not the primary cause of crackles or orthopnea.
Correct Answer is B
Explanation
A. Making a clinical decision in the patient's best interest: Making decisions in the patient’s best interest is an essential part of nursing practice and demonstrates good clinical judgment.
B. Making a clinical decision based on previous shift assessments. Nursing assessments should be conducted for each shift, as a patient’s condition can change rapidly. Relying on previous assessments without reassessing can lead to missed changes in the patient’s status, potentially causing harm.
C. Making an ethical clinical decision. Ethical decision-making is an integral part of nursing practice and aligns with professional standards. There is no need for intervention if the decision is ethical.
D. Making an informed clinical decision. Informed clinical decision-making is based on current patient data, clinical guidelines, and critical thinking. This is a correct approach to nursing care and does not require intervention.
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