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 incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.
Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.
Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 8 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.
Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because the patient who is nauseated and vomiting after receiving narcotic pain medication is not the most urgent patient. Nausea and vomiting are common side effects of narcotic pain medication and can be managed with antiemetics and hydration. The patient's condition is not life-threatening and does not require immediate intervention.
Choice B reason: This is an incorrect choice because the patient who is waiting for discharge teaching in order to go home is not the most urgent patient. Discharge teaching is an important part of patient education and care transition, but it can be delayed until the more critical patients are attended to. The patient's condition is stable and does not require immediate intervention.
Choice C reason: This is the correct choice because the patient with chest pain after two doses of sublingual nitroglycerin is the most urgent patient. Chest pain is a sign of myocardial ischemia, which can lead to myocardial infarction or heart attack. Sublingual nitroglycerin is a medication that dilates the coronary arteries and relieves chest pain. If the chest pain persists after two doses of sublingual nitroglycerin, the patient may have unstable angina or acute coronary syndrome, which are medical emergencies that require immediate intervention⁴.
Choice D reason: This is an incorrect choice because the constipated patient who needs to use the toilet after receiving a laxative is not the most urgent patient. Constipation is a common gastrointestinal problem that can be treated with laxatives and dietary changes. The patient's condition is not life-threatening and does not require immediate intervention.
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