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 ["A","B","C"]
Explanation
A. Applying warm compresses can help relieve discomfort
B. Regular monitoring of skin moisture is crucial in managing IAD. Moist skin is more susceptible to breakdown, so frequent checks allow for prompt intervention, such as changing incontinence products or applying protective barriers.
C. Applying a moisture barrier product after cleansing helps protect the skin from moisture and irritants found in urine or feces. These products create a protective barrier that can prevent further damage and promote healing of already affected skin. This is essential in managing IAD.
D There is no clinical
Rationale to decrease oral intake in the early morning specifically for managing IAD. Hydration is important for overall skin health, and reducing oral intake without medical indication could lead to dehydration, which may worsen skin condition.
E. Vigorous drying of the skin is not recommended as it can exacerbate skin irritation and damage. Instead, gentle patting or air drying is preferred to avoid further trauma to the already compromised skin.
Correct Answer is A
Explanation
A. Gender can influence health beliefs and practices due to societal norms, roles, and expectations associated with masculinity and femininity. For example, certain health issues may be more prevalent or
stigmatized based on gender. Understanding a client's gender-related health beliefs can help nurses tailor care that respects and addresses these factors.
B. Socioeconomic status (SES) impacts access to healthcare resources, health literacy, and health behaviors. Clients with higher SES may have greater access to healthcare facilities, medications, and preventive services. However, this is an external variable.
C. Family health practices often shape an individual's beliefs about health and illness. Clients may adopt health behaviors based on familial traditions, cultural practices, or experiences with illness within the family. However, this is an external variable.
D. Education level influences health literacy, understanding of medical information, and decision-making regarding healthcare. Higher education levels are often associated with better health outcomes due to increased knowledge of health-related issues, ability to navigate healthcare systems, and adherence to medical advice. However, this is an external variable.
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