After taking the patient's temperature, the nurse documents the value and the route used to do the reading. What is the reason for the nurse's action?
Temperatures vary depending on the route used.
Temperatures are readings of core measurements.
Rectal temperatures are cooler than when taken orally.
Axillary temperatures are higher than oral temperatures.
The Correct Answer is A
A. Temperatures vary depending on the route used:
Each route (oral, rectal, axillary, tympanic) has different baseline readings. Accurate documentation helps interpret the result correctly.
B. Temperatures are readings of core measurements:
Only rectal and tympanic routes give true core temperatures. Oral and axillary are surface-level and influenced by environment.
C. Rectal temperatures are cooler than when taken orally:
This is incorrect-rectal temperatures are typically 0.5–1°F higher than oral temperatures.
D. Axillary temperatures are higher than oral temperatures:
Axillary temps are lower than oral, not higher.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Side-to-side:
This technique allows for comparison of corresponding areas on both lungs to detect asymmetry in breath sounds.
B. Top-to-bottom:
While commonly used during general assessments, this method alone does not allow for comparison between the lungs.
C. Posterior-to-anterior:
This is not a method for auscultation comparison. Lungs are assessed posteriorly and anteriorly, but not as a comparison method.
D. Interspace-by-interspace:
This refers to location, not comparison technique. Side-to-side ensures symmetry is assessed properly.
Correct Answer is ["A","B","C","E"]
Explanation
A. Betadine:
Betadine (povidone-iodine) is commonly used for cleansing the perineal area. Patients may have an allergy to iodine-based antiseptics.
B. Shellfish:
A shellfish allergy may indicate a sensitivity to iodine, which is found in Betadine. While this connection is debated, many protocols still recommend caution.
C. Latex:
Many catheters and gloves are made with latex, which can cause serious allergic reactions, including anaphylaxis.
D. Silicone:
Silicone is hypoallergenic and usually used for patients with latex allergies. True silicone allergies are rare.
E. Tape:
Tape is used to secure the catheter tubing. Some patients have adhesive allergies that can cause skin irritation or blisters.
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