The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.
Which action should the nurse implement?

Remind the UAP to locate the thermometer before gently inserting the ear.

Demonstrate the correct technique for pulling the client's auricle up and back.

Advise the UAP to hold the thermometer securely in place to obtain the measurement.

Use positive reinforcement to affirm that the procedure being performed correctly.

Answer and Explanation

The Correct Answer is D

The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.

Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.

Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.

Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.

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Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

Correct Answer is ["16"]

Explanation

The healthcare provider prescribed 800,000 units of penicillin and the vial available is labeled 50,000 units/mL.

To calculate the number of mL to administer, you need to divide the total number of units prescribed (800,000) by the number of units per mL (50,000).

This gives you a result of 16 mL.

Therefore, the nurse should administer 16 mL of penicillin to the patient.

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The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

Correct Answer is ["16"]

Explanation

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The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.
Which action should the nurse implement?