A nurse plans to measure a client's temperature orally. Which action should the nurse take first to ensure an accurate measurement?

Ask the client to breathe through their mouth during the temperature measurement.

Place the thermometer directly under the client's tongue immediately after removing it from the probe cover.

Ask the client if they have consumed hot or cold food, beverages, or smoked within the last 15 minutes.

Instruct the client to keep their mouth slightly open during the measurement.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Asking the client to breathe through their mouth during measurement is not necessary for accuracy and may actually cool the oral cavity, affecting the reading. This action is not the first step in ensuring a precise temperature measurement.

B. Placing the thermometer under the tongue immediately is premature. If the client recently consumed hot or cold foods, beverages, or smoked, the oral temperature reading may be inaccurate. Verifying recent intake is essential before placement.

C. Asking the client if they have consumed hot or cold food, beverages, or smoked within the last 15 minutes is the first and most important step to ensure accuracy. Recent oral intake or smoking can transiently elevate or lower oral temperature readings, leading to false results. Waiting at least 15 minutes after these activities helps ensure the measurement reflects the body’s core temperature.

D. Instructing the client to keep their mouth slightly open may interfere with proper placement of the thermometer under the tongue. For accuracy, the client should close their lips gently around the probe, preventing external air from affecting the reading.

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Correct Answer is D

Explanation

Rationale:

A. The patient's recent travel destinations may be relevant in certain contexts, such as exposure to infectious diseases, but it is not universally essential for understanding the overall health status. It is supplementary information rather than a core component of a comprehensive health history.

B. The patient's foods and dietary preferences provide insight into nutrition and cultural considerations, but they do not directly identify current health risks, disease management, or potential drug interactions. While valuable, this information is not the highest priority for assessing health status.

C. The patient's preferred pharmacy and insurance information are administrative details that facilitate prescription management and billing, but they do not provide clinical insight into the patient’s health. They are important for logistics but not for evaluating medical status.

D. Current medications, including dosage and frequency, are the most critical information to collect. This data provides a clear picture of ongoing treatments, potential side effects, drug interactions, adherence issues, and the management of chronic or acute conditions. Understanding medications is essential for planning safe care, identifying contraindications, and ensuring accurate assessment and intervention.

A. Chronic hypoxia B. Iron deficiency anemia C. Peripheral edema D. Hyperthyroidism

Correct Answer is B

Explanation

Rationale:

A. While chronic hypoxia can cause changes in nail appearance, such as clubbing (rounded, bulbous fingertips with nails curving downward), it does not cause spoon-shaped nails. Therefore, chronic hypoxia is incorrect.

B. Spoon-shaped nails, or koilonychia, are a classic sign of iron deficiency anemia. In this condition, the nails become thin, concave, and may have raised ridges, resembling a spoon. This occurs due to impaired hemoglobin production and associated tissue hypoxia, which affects nail formation. Other signs of iron deficiency anemia may include pallor, fatigue, brittle hair, and glossitis (smooth, sore tongue).

C. Edema causes swelling of soft tissues in the extremities, including around the nails, but it does not produce the concave, spoon-shaped appearance characteristic of koilonychia.

D. Hyperthyroidism may cause nail thinning, brittle nails, or onycholysis (separation of the nail from the nail bed), but it does not cause spoon-shaped nails.

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A nurse plans to measure a client's temperature orally. Which action should the nurse take first to ensure an accurate measurement?

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Naxlex Comprehensive Predictor Exams

When conducting a health history prior to a nursing assessment, which of the following is the most important information to collect to ensure a comprehensive understanding of the patient's health status?

Correct Answer is D

Explanation

During a physical examination, the nurse observes spoon-shaped nails (koilonychia). Which condition should the nurse suspect?

Correct Answer is B

Explanation

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