The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?
Along either upper gum line, adjacent to an incisor.
Deep in the posterior sublingual pocket.
In the inferior buccal space on either side of the tongue.
Superior to the tongue with the tip touching the hard palate.
The Correct Answer is B
A. Along either upper gum line, adjacent to an incisor: Placing the thermometer along the upper gum line near the incisors would not accurately reflect the body's core temperature. The posterior sublingual pocket provides a more reliable reading.
B. Deep in the posterior sublingual pocket: The sublingual pocket, located under the tongue toward the back, is the best place for measuring oral temperature. This area has a good blood supply from the carotid arteries, making it ideal for an accurate temperature reading.
C. In the inferior buccal space on either side of the tongue: The buccal space is not ideal for temperature measurement, as it does not have the same consistent blood supply and is more prone to error due to airflow from breathing.
D. Superior to the tongue with the tip touching the hard palate: Placing the thermometer on top of the tongue against the hard palate would result in an inaccurate reading because this location does not effectively reflect the body's core temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Skin fold returns to its usual shape quickly when released. When assessing skin turgor, the nurse is checking for the elasticity and hydration of the skin. In a normal assessment, when the skin fold is lifted or pinched, it should return to its usual shape quickly when released. This indicates good skin turgor, which is an indication of proper hydration. If the skin fold is difficult to lift or pinch (choice A), this indicates poor skin turgor and possible dehydration. If an indentation of 2 mm remains after releasing the skin fold (choice B), this indicates poor skin turgor and possible dehydration. If the skin fold returns to its usual shape slowly when released (choice D), this may indicate a decrease in skin elasticity and possible dehydration.
Correct Answer is C
Explanation
Answer and Explanation
The correct answer is choice C, Read back the order to the physician.
After obtaining the physician's order over the phone, the nurse should read back the order to the physician to confirm accuracy and prevent medication errors.
This process ensures that the order is correctly transcribed and the right medication, dose, and route are given to the patient. Calling the pharmacy to check medication availability is not the nurse's responsibility, and initiating the prescription and administering the medication is inappropriate without confirming the order with the physician. Drawing up the medication into an appropriately labeled syringe before confirming the order with the physician is also inappropriate and can lead to medication errors. Therefore, reading back the order to the physician is the most appropriate action for the nurse to take.
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