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. Delirium is often reversible once the underlying cause is identified and treated (e.g., correcting electrolyte imbalances, managing infections, discontinuing medications contributing to delirium). With appropriate intervention, the mental status can improve, and the individual can return to their baseline cognitive function.
A. Dementia, on the other hand, is a chronic, progressive syndrome that primarily affects memory, thinking, behavior, and the ability to perform everyday activities. It does not typically cause acute changes in consciousness.
B. Memory impairment is a hallmark feature of dementia, especially in the early stages. In contrast, delirium primarily affects attention, awareness, and cognition acutely, with memory impairment being variable and not a defining feature.
D. Delirium develops rapidly, often over hours to days, in response to an acute medical condition, medication change, or other factors. It is characterized by a fluctuating course and can resolve once the underlying cause is managed.
Correct Answer is ["B","E"]
Explanation
B Droplet precautions are used for pathogens that can be transmitted through respiratory droplets produced when an infected person coughs, sneezes, talks, or during procedures such as suctioning.
E. Healthcare workers should wear a surgical mask when within close proximity (within 3 feet) of a patient on droplet precautions. The mask helps prevent the inhalation of droplets that may contain infectious pathogens.
A. Negative pressure rooms are used for airborne precautions, not droplet precautions. Droplet precautions typically do not require negative pressure rooms.
C. Infections transmitted on air currents are managed with airborne precautions, not droplet precautions. Droplet transmission occurs over shorter distances (generally within 3 feet) due to larger respiratory droplets.
D. An N-95 mask is used for airborne precautions to filter smaller particles. For droplet precautions, healthcare workers typically wear a surgical mask to protect against larger respiratory droplets.
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