While inserting a rectal thermometer, the nurse encounters resistance. The nurse should:

Ask the client to take deep breaths

Remove the thermometer and reinsert more forcefully

Apply mild pressure to advance

Remove the thermometer immediately

Answer and Explanation

The Correct Answer is D

A. Ask the client to take deep breaths. Deep breathing can help relax the anal sphincter, but if resistance is already encountered, forcing the thermometer further could cause injury.
B. Remove the thermometer and reinsert more forcefully. Forcing the thermometer can cause damage to the rectal mucosa, leading to pain, bleeding, or even perforation.
C. Apply mild pressure to advance. Any resistance suggests a possible obstruction, such as stool or anatomical issues. Applying pressure could cause harm, so the thermometer should not be advanced further.
D. Remove the thermometer immediately. If resistance is encountered, the safest action is to withdraw the thermometer to prevent injury. The nurse should reassess the situation and consider alternative temperature measurement methods.

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Correct Answer is B

Explanation

A. Take the temperature for 6-8 minutes. Modern digital thermometers provide accurate readings within seconds to a minute, making such a long duration unnecessary.
B. Wear gloves throughout the procedure. Gloves must be worn to maintain infection control and hygiene, as rectal temperature measurement involves contact with mucous membranes and potential exposure to bodily fluids.
C. Place the patient in the prone position. The left lateral (Sims') position is the preferred position for rectal temperature measurement, as it provides better access and comfort.
D. Insert the thermometer 2.5 inches into the patient's anus. For adults, the correct insertion depth is 1.5 inches (3-4 cm), while for infants, it is only 0.5 inches (1.3 cm) to prevent injury.

A. Regular use of narcotic analgesics leads to drug addiction B. Amount of pain is reflective of actual tissue damage C. Patients are the best judges of their pain D. Chronic pain is psychological in nature

Correct Answer is C

Explanation

A. Regular use of narcotic analgesics leads to drug addiction. While opioids can cause dependence with prolonged use, addiction is characterized by compulsive drug-seeking behavior. When used appropriately for pain management, addiction risk is low.
B. Amount of pain is reflective of actual tissue damage. Pain perception varies widely among individuals. Some may experience severe pain with minimal tissue damage, while others may have little pain despite significant injury.
C. Patients are the best judges of their pain. Pain is subjective, and only the patient can accurately describe its intensity and quality. Nurses should trust the patient's self-report rather than rely solely on appearance or behavior.
D. Chronic pain is psychological in nature. Chronic pain often has a physiological basis, such as nerve damage or inflammation, though psychological factors can influence pain perception. It is not purely psychological.

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While inserting a rectal thermometer, the nurse encounters resistance. The nurse should:

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Naxlex Comprehensive Predictor Exams

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