You have delegated vital signs to the assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to
Walt 30 minutes and take an oral temperature
Advise the patient to drink a glass of cold water
Take a rectal temperature
Take the oral temperature as planned
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Errors by the nurse assistant in measuring temperature. While improper technique can lead to inaccurate readings, consistent temperature fluctuations in a head injury patient are more likely due to hypothalamic dysfunction.
B. Increased vasodilatation of the superficial vessels contributing to excess heat losses. Vasodilation can play a role in heat loss, but it does not fully explain difficulty maintaining body temperature, which is primarily regulated by the hypothalamus.
C. The client's head injury causing interference with the function of the hypothalamus. The hypothalamus regulates body temperature, and a severe head injury can disrupt this function, leading to temperature instability (neurogenic fever or hypothermia) despite the absence of infection.
D. Choosing the wrong time of day to obtain vital signs. While body temperature naturally fluctuates throughout the day, major instability in temperature regulation is not due to the timing of measurement but rather an issue with the hypothalamus.
Correct Answer is ["10"]
Explanation
To convert teaspoons (tsp) to milliliters (mL), the conversion factor is:
1tsp=5mL1
Given:
- 2 tsp
2 × 5mL = 10mL
Thus, 2 tsp = 10 mL.
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