What intervention should the practical nurse (PN) implement when taking the rectal temperature of an adult client?

Hold the thermometer the entire time while taking the temperature.

Place the client in the right Fowler's position.

Lubricate the tip of the thermometer with water.

Gently insert the thermometer 3 inches into the rectum.

Answer and Explanation

The Correct Answer is A

A. Hold the thermometer the entire time while taking the temperature: Holding the thermometer or probe prevents it from being inadvertently displaced or pushed further into the rectum by peristalsis or client movement, which could lead to rectal perforation or injury to the delicate anal and rectal tissues.

B. Place the client in the right Fowler's position: The right lateral (Sims’) position, not Fowler’s, is recommended for rectal temperature measurement. Positioning in Fowler’s does not provide optimal access or safety for this procedure.

C. Lubricate the tip of the thermometer with water: The tip of the rectal thermometer or probe must be lubricated with a water-soluble lubricant (e.g., K-Y Jelly), not just water. Lubrication significantly reduces friction and discomfort upon insertion, thereby minimizing the risk of irritation or trauma to the rectal mucosa.

D. Gently insert the thermometer 3 inches into the rectum: Inserting the thermometer too far can cause rectal trauma. The recommended depth for an adult is approximately 1–1.5 inches; 3 inches is excessive.

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Correct Answer is B

Explanation

A. Speak louder so the client can hear the conversation: Raising the voice may distort sounds and make speech harder to understand, especially for those with sensorineural hearing loss. It can also be perceived as shouting, which may cause discomfort or embarrassment for the client.

B. Determine if the client has had difficulty hearing in the past: Assessing whether the hearing difficulty is new or chronic is the most important initial step. This helps identify if the issue is due to a reversible cause, such as earwax buildup, or if accommodations, like hearing aids or alternative communication methods, are needed.

C. Encourage the client to read the practical nurse’s lips: While lip-reading can assist communication, it should not be the first approach before determining the cause and extent of the hearing problem. Some clients may also have visual impairments that limit this strategy.

D. Provide written instructions about how to take medications: Written instructions are useful for clients with known hearing loss, but they should be supplemented with an assessment first to ensure comprehension and to tailor the communication method appropriately.

A. Encourage a low carbohydrate diet. B. Use a cushion when sitting. C. Perform range of motion exercises. D. Discuss a low sodium diet.

Correct Answer is D

Explanation

A. Encourage a low carbohydrate diet: Carbohydrate restriction does not address fluid retention, edema, or electrolyte imbalances associated with chronic kidney disease and is not the priority intervention in this scenario.

B. Use a cushion when sitting: This intervention may help prevent skin breakdown, but it does not address the underlying fluid overload or electrolyte imbalance.

C. Perform range of motion exercises: ROM exercises support joint mobility and circulation, but they do not directly manage fluid retention or prevent further complications from electrolyte disturbances.

D. Discuss a low sodium diet: Sodium restriction helps manage fluid retention, edema, and blood pressure in clients with chronic kidney disease. Implementing a low-sodium diet directly targets the cause of weight gain and generalized edema, making it the priority intervention.

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What intervention should the practical nurse (PN) implement when taking the rectal temperature of an adult client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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