The nurse takes a client's temperature and gets an unexpected result. Which site would provide the most accurate temperature reading?
Axillary
Skin
Oral
Rectal
The Correct Answer is D
D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.
A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.
B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.
C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. If the stressor persists for a prolonged period and the body is unable to adapt or cope effectively, it enters the exhaustion phase. During this phase, the body's resources become depleted. The client experiences decreased energy, reduced ability to cope with stress, and may develop stress-related illnesses or complications.
A. It is characterized by the body's immediate response to a stressor, where physiological changes occur such as increased heart rate, heightened senses, and activation of the fight-or-flight response.
B. After the initial alarm reaction, if the stressor persists, the body enters the resistance phase. In this phase, physiological changes stabilize as the body attempts to cope with the stressor.
D. This phase occurs if the stressor is removed or successfully managed, allowing the body to recover and return to a state of homeostasis. During recovery, the body repairs any damage caused by the stress response and replenishes its energy and resources.
Correct Answer is D
Explanation
D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable
A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.
B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.
C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.
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