The nurse is caring for a patient who came to the emergency department with confusion and muscle cramps after working outside on a hot day. What is the priority action of the nurse?

A. Axillary. The axillary method is less accurate because it measures surface temperature, which can be influenced by environmental factors and is typically lower than core temperature.
B. Rectal. The rectal route provides the most accurate core temperature measurement because it closely reflects internal body temperature and is less affected by external conditions. It is commonly used in critically ill patients and infants when precise measurements are needed.
C. Forehead. Forehead (temporal artery) thermometers provide a non-invasive method of measuring temperature but can be less accurate due to external factors like sweating or ambient temperature changes.
D. Oral. Oral temperature is commonly used and provides a good estimate of core temperature, but factors like recent eating, drinking, or mouth breathing can affect accuracy. Rectal temperature remains the most precise method.

A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.