Which technique will provide the most accurate measurement of the patient’s core temperature?
Axillary
Orally
Rectally
Forehead
The Correct Answer is C
Choice A reason: This is an incorrect choice because the axillary method is not the most accurate measurement of the core temperature. The axillary method involves placing a thermometer under the patient's armpit and measuring the temperature of the skin surface. This method can be affected by factors such as sweating, clothing, and ambient temperature. The axillary method can underestimate the core temperature by 0.5°C to 1.5°C¹.
Choice B reason: This is an incorrect choice because the oral method is not the most accurate measurement of the core temperature. The oral method involves placing a thermometer in the patient's mouth and measuring the temperature of the sublingual pocket. This method can be affected by factors such as eating, drinking, smoking, and mouth breathing. The oral method can underestimate the core temperature by 0.3°C to 0.8°C¹.
Choice C reason: This is the correct choice because the rectal method is the most accurate measurement of the core temperature. The rectal method involves inserting a thermometer into the patient's rectum and measuring the temperature of the rectal mucosa. This method reflects the temperature of the blood flowing through the core of the body. The rectal method is considered the gold standard for measuring the core temperature¹.
Choice D reason: This is an incorrect choice because the forehead method is not the most accurate measurement of the core temperature. The forehead method involves placing a thermometer on the patient's forehead and measuring the temperature of the temporal artery. This method can be affected by factors such as sweating, hair, and ambient temperature. The forehead method can overestimate or underestimate the core temperature by 0.5°C to 1°C¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Choice B reason: This is the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is relevant, open-ended, and comprehensive. The nurse should ask questions that are related to the patient's health status, needs, or goals, and that elicit more information from the patient. This question allows the patient to describe the onset, duration, and frequency of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.
Choice C reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Choice D reason: This is not the most important question for the nurse to ask the patient who has just arrived at the hospital with chest pain because it is not relevant, open-ended, or comprehensive. The nurse should not ask questions that are not related to the patient's health status, needs, or goals, but rather focus on the patient's chief complaint, history of present illness, and past medical history.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because "Are you having any difficulty breathing right now?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to describe their condition in detail.
Choice B reason: This is the correct choice because "What does your chest pain feel like?" is an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question invites the patient to describe the quality, intensity, location, and duration of their chest pain, which can help the nurse to assess the possible cause and severity of the problem.
Choice C reason: This is an incorrect choice because "Do you have a family history of heart disease?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a yes or no, and does not encourage the patient to provide more details about their health history or risk factors.
Choice D reason: This is an incorrect choice because "How long have you been experiencing chest pain?" is not an open-ended question. An open-ended question is a question that requires more than a yes or no answer and elicits more information from the speaker. This question can be answered with a specific time, and does not encourage the patient to provide more information about their symptoms or situation.
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