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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wait 30 minutes and take an oral temperature. Waiting 30 minutes ensures an accurate reading, as consuming hot or cold foods or drinks can alter oral temperature results.
B. Advise the patient to drink a glass of cold water. Drinking cold water could artificially lower the oral temperature, leading to an inaccurate measurement.
C. Take a rectal temperature. A rectal temperature is not necessary in this situation unless a core temperature is required for clinical reasons.
D. Take the oral temperature as planned. Taking the oral temperature immediately after hot soup can result in a falsely elevated reading, making it unreliable.
Correct Answer is ["39.2"]
Explanation
Calculation:
The formula to convert Fahrenheit (°F) to Celsius (°C) is:
°C = (°F - 32) × 5/9
= (102.5 - 32) × 5/9
= (70.5) × 5/9
= 39.1666...
Rounding to the nearest tenth: 39.2 °C.
Therefore, 102.5 °F is equal to 39.2 °C.
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