Which patient should have the temperature taken orally rather than using a tympanic thermometer?
An unconscious, intubated patient
A patient with bilateral middle ear infections
An agitated patient who cannot follow directions
A patient with gastroenteritis who is vomiting
The Correct Answer is B
A. An unconscious, intubated patient. An oral temperature is not appropriate for an unconscious or intubated patient due to the risk of injury and inability to follow instructions. A tympanic, rectal, or axillary method would be preferred.
B. A patient with bilateral middle ear infections. Tympanic thermometers measure temperature through the ear canal and tympanic membrane, which can be affected by infection or inflammation, leading to inaccurate readings. An oral or alternative method is preferred.
C. An agitated patient who cannot follow directions. Oral temperature requires cooperation, so it would not be suitable for an agitated patient who may bite or not keep the thermometer in place. A tympanic or axillary method would be better.
D. A patient with gastroenteritis who is vomiting. Vomiting can make oral temperature measurement uncomfortable and impractical. A tympanic, axillary, or rectal method would be more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "The top number is the systolic blood pressure and reflects the pressure on the arteries when the heart contracts." The systolic pressure (118 mmHg) represents the force exerted on the arterial walls when the heart contracts and pumps blood.
B. "The numbers are within normal range and nothing to worry about." While 118/82 mmHg is within the normal range, this response does not explain what the numbers mean, which was the patient’s question.
C. "The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure." While the systolic pressure is important, the diastolic pressure is also crucial for assessing cardiovascular health. This response also discourages patient education.
D. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." Diastolic pressure (82 mmHg) represents the pressure in the arteries when the heart is at rest, not stroke volume, which refers to the amount of blood ejected per heartbeat.
Correct Answer is ["A","B","C"]
Explanation
A. Pulse of smooth contour with 2+ amplitude. A normal pulse should have a smooth upstroke and downstroke with a moderate (2+) amplitude, indicating adequate blood flow and cardiac function.
B. Heart rate of 62 beats/min. A normal resting heart rate for a healthy adult range from 60 to 100 beats per minute. A heart rate of 62 bpm is within this normal range.
C. S1 and S2 present with regular rhythm. The first (S1) and second (S2) heart sounds should be audible and regular, indicating normal closure of the heart valves and a steady cardiac rhythm.
D. Mild, pedal edema. Pedal edema is not a normal finding in a healthy adult and may indicate fluid retention or cardiovascular issues such as heart failure or venous insufficiency.
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