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. A sunken anterior fontanel is not an expected finding in healthy infants. Normally, the anterior fontanel is level with the surrounding skull and may pulsate slightly with the heartbeat.

B. Increased intracranial pressure typically causes the fontanel to bulge, not sink. A bulging fontanel may indicate conditions such as hydrocephalus, meningitis, or intracranial hemorrhage.

C. While the fontanel allows for brain growth and skull expansion, a sunken fontanel does not indicate normal brain development. Normal development is reflected by a soft, flat, and appropriately sized fontanel.

D. A sunken anterior fontanel is a classic sign of dehydration in infants. Dehydration reduces the volume of intracranial fluid and tissues, causing the soft spot to appear concave. Other signs of dehydration may include dry mucous membranes, decreased urine output, lethargy, and poor skin turgor.

A. Accurate blood pressure reading with possible discomfort B. The reading will be falsely low C. Inability to obtain any blood pressure reading D. Falsely elevated blood pressure reading

Correct Answer is D

Explanation

Rationale:

A. This is incorrect because accuracy depends on using a correctly sized cuff. While a cuff that is too small may cause discomfort due to tightness, it will not provide a true measurement of the patient’s blood pressure. Discomfort alone does not ensure an accurate reading.

B. A cuff that is too large for the patient can cause falsely low readings because the cuff more easily compresses the artery. However, when the cuff is too small, the opposite occurs: the nurse must inflate the cuff to a higher pressure to occlude the artery, resulting in a falsely elevated reading.

C. Generally, a small cuff can still provide a reading. The problem is not that a measurement cannot be taken, but that the reading is inaccurate and consistently higher than the true blood pressure.

D. Using a cuff that is too small for the patient’s arm circumference increases the pressure needed to occlude the artery, leading to an overestimation of both systolic and diastolic blood pressures. This is a common error in clinical practice, particularly in patients with larger arms. Using the proper cuff size — where the bladder width is approximately 40% of the arm circumference and the length covers 80–100% of the arm — ensures accurate blood pressure readings and reduces the risk of misdiagnosis or inappropriate treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an infant during a routine health examination. The nurse notes that the infant's anterior fontanel is sunken. How should the nurse interpret this finding?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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