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 ["15"]

Explanation

Calculation:

To determine the volume to administer, use the formula:

Volume = (Dose ordered/ Dose available)× mL per dose

Given:

Ordered dose = 37.5 mg
Available concentration = 12.5 mg/5 mL

Volume = (37.5/12.5)× 5mL

= 3× 5mL

= 15mL

Thus, the nurse will administer 15 mL.

A. B B. A C. D D. C

Correct Answer is C

Explanation

Client A has normal vital signs except for a mild fever, no urgent intervention needed.

Client B shows mild tachycardia and increased respiratory rate, but oxygen saturation and blood pressure remain stable, requires monitoring but not immediate action.

Client C has fever, tachycardia, and tachypnea, suggesting infection or dehydration. While assessment is needed, the patient is not in immediate distress compared to Client D.

Client D requires immediate nursing intervention due to the following critical findings: Bradycardia which may indicate poor perfusion, conduction abnormalities, or medication side effects, bradypnea can signal respiratory depression or impending failure, hypotension suggests shock or decreased perfusion, which may lead to organ failure and hypoxia, oxygen saturation below 90% is a critical finding and requires immediate intervention.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Covert 102.5 Fahrenheit to C (round to tenths)