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 D
Explanation
A. 40-year-old with a pulse of 88. A resting pulse of 88 beats per minute is within the normal adult range (60–100 bpm) and does not require further assessment.
B. 18-year-old with a pulse rate of 140 after riding 2 miles on an exercise bike. An increased heart rate after exercise is a normal physiological response, and the heart rate should return to baseline after rest. No further assessment is needed unless tachycardia persists.
C. 50-year-old man with a BP of 112/60 mmHg on awakening in the morning. This blood pressure is within a normal range, especially in the early morning when BP is often lower. No additional assessment is required.
D. 65-year-old with a respiratory rate of 10/min. A normal respiratory rate for an adult is 12–20 breaths per minute. A respiratory rate of 10 is lower than normal and may indicate respiratory depression, which could be caused by medications such as opioids, neurological issues, or other conditions requiring further evaluation.
Correct Answer is A
Explanation
A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.
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