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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Don't worry. The cancer prevents you from becoming addicted." This statement is incorrect because having cancer does not prevent addiction. However, appropriate pain management in patients with severe pain does not typically lead to addiction.
B. "That is a valid worry. I wouldn't want to become addicted." While acknowledging the patient’s concern is important, this response reinforces fear rather than providing reassurance based on medical evidence.
C. "My cousin was addicted to pain killers when he had cancer." This response is inappropriate because it is anecdotal and does not address the patient’s concern with factual medical information.
D. "Because you have severe pain, the medication is necessary. There is little chance of addiction as long as you take the medication as prescribed." This is the best response because it reassures the patient that pain control is a priority and that, when used correctly, the risk of addiction is minimal.
Correct Answer is C
Explanation
A. Inform the patient's health care provider immediately to obtain an order for antihypertensive medications. While notifying the provider may be necessary, the nurse must first confirm the accuracy of the blood pressure reading before taking further action.
B. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. Nursing assistants can take blood pressure readings, but the nurse should personally verify a critically high reading using a manual method.
C. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope. Electronic monitors can sometimes give false readings, especially in patients with irregular heartbeats or movement. Manually verifying ensures an accurate assessment before determining further action.
D. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. A neurological assessment is important if the elevated BP is confirmed, but the first priority is verifying the reading manually.
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