The nurse must take a patient's rectal temperature. Which should the nurse do?

Take the temperature for 6-8 minutes

Wear gloves throughout the procedure

Place the patient in the prone position

Insert the thermometer 2.5 inches into the patient's anus

Answer and Explanation

The Correct Answer is B

A. Take the temperature for 6-8 minutes. Modern digital thermometers provide accurate readings within seconds to a minute, making such a long duration unnecessary.
B. Wear gloves throughout the procedure. Gloves must be worn to maintain infection control and hygiene, as rectal temperature measurement involves contact with mucous membranes and potential exposure to bodily fluids.
C. Place the patient in the prone position. The left lateral (Sims') position is the preferred position for rectal temperature measurement, as it provides better access and comfort.
D. Insert the thermometer 2.5 inches into the patient's anus. For adults, the correct insertion depth is 1.5 inches (3-4 cm), while for infants, it is only 0.5 inches (1.3 cm) to prevent injury.

Nursing Test Bank

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Correct Answer is ["2"]

Explanation

Calculation:

Formula:

Tabletsperdose = Dose ordered/ Dose available

Given:

Ordered dose = 100 mg
Available dose = 50 mg per tablet

Tablets per dose = 100mg/ (50mg/tablet)

= 2 tablets

Thus, the nurse will administer 2 tablets per dose.

A. have another nurse recheck your findings for accuracy. B. record the vital signs and compare them with previously charted vital signs. C. report them to the charge nurse and call the doctor for orders. D. instruct the client on diet and exercise for high blood pressure.

Correct Answer is B

Explanation

A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.

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The nurse must take a patient's rectal temperature. Which should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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