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 D
Explanation
A. Request an order for a urinalysis with culture and sensitivity:
There is no indication of infection (e.g., no cloudy urine, odor, or fever), so a C&S is not warranted at this point.
B. Irrigate the patient’s catheter using 60 mL of sterile normal saline:
Irrigation should only be done with a provider’s order or if there is a clear obstruction, which is not the case here.
C. Remove the catheter immediately and notify the health care provider:
Removing without an order or plan can put the patient at risk, especially with a spinal cord injury and potential retention issues.
D. Contact the health care provider for an order to change the catheter:
Long-term indwelling catheters are typically changed every 4 to 12 weeks to reduce infection risk and ensure function. This is the safest and most appropriate next step.
Correct Answer is F,E,A,C,B,D
Explanation
A. Clean injection port:
This is done after clamping and before connecting the syringe to prevent introducing infection.
B. Inject prescribed solution:
Done only after the syringe is connected to the port.
C. Twist needleless syringe into port:
This ensures a secure and sterile connection before irrigation.
D. Remove clamp and allow to drain:
This step ensures the irrigant and urine can flow out properly after irrigation.
E. Clamp catheter just below specimen port:
Done early to allow retention of solution during irrigation and prevent backflow.
F. Draw up prescribed amount of sterile solution ordered:
First step—preparing the exact amount of irrigation fluid needed.
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