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.

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Correct Answer is ["0.5"]

Explanation

To determine the number of tablets per dose, use the formula:

Tablets per dose = Dose ordered/Dose available

Given:

Ordered dose = 400 mg
Available dose = 800 mg per tablet

Tablets per dose = 400mg/(800mg/tablet)

= 0.5 tablet

Thus, the nurse will administer 0.5 tablet per dose.

A. Irritating cough B. Tachypnea C. Hypertension D. Urinary retention

Correct Answer is D

Explanation

A. Irritating cough. Opioid agonists do not typically cause an irritating cough. In fact, opioids like codeine are used as antitussives to suppress cough reflexes.
B. Tachypnea. Opioids depress the central nervous system, leading to respiratory depression rather than an increased respiratory rate (tachypnea). The nurse should monitor for bradypnea instead.
C. Hypertension. Opioids commonly cause hypotension due to vasodilation and central nervous system depression. Hypertension is not a typical adverse effect.
D. Urinary retention. Opioids can increase sphincter tone and suppress the urge to void, leading to urinary retention. This is a known side effect and should be monitored, especially in older adults or those with underlying bladder issues.

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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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