A nurse is about to take a client’s oral temperature, but the client has just consumed some ice chips. What should the nurse do next?

Wait for 30 minutes and then measure the client’s oral temperature.

Proceed to measure the client’s oral temperature immediately.

Document the inability to obtain an accurate reading of the client’s oral temperature.

Provide the client a sip of warm water and wait 5 minutes before measuring his oral temperature.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The nurse should wait for 30 minutes and then measure the client’s oral temperature. Consuming cold substances like ice chips can temporarily lower the oral temperature, leading to inaccurate readings. Therefore, it’s recommended to wait for a period of time to allow the oral temperature to return to its normal state.
Choice B rationale
Proceeding to measure the client’s oral temperature immediately after consuming ice chips would likely result in an inaccurately low reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Documenting the inability to obtain an accurate reading of the client’s oral temperature is not the best action in this situation. While it’s important to document any factors that might affect the accuracy of a temperature reading, in this case, the nurse can simply wait a period of time after the client has consumed the ice chips before taking the oral temperature.
Choice D rationale
Providing the client a sip of warm water and waiting 5 minutes before measuring his oral temperature may not be sufficient to ensure an accurate temperature reading. The mouth needs adequate time to return to its normal temperature after consuming something cold.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

The statement “The client should first move the strong leg then the weak one” is not the best practice when using a cane. The client should move the cane and the weak leg forward at the same time, then move the strong leg.
Choice B rationale
The statement “When the client moves, he should move the cane forward first” is the correct practice. Moving the cane first provides stability and support for the next step.
Choice C rationale
The statement “The client should hold the cane on the weak side of his body” is not the correct practice. The cane should be held on the strong side of the body to provide support for the weak side.
Choice D rationale
The statement “The grip should be level with the client’s waist” is a good practice, but it’s not the best answer for this question. The grip of the cane should be at the level of the client’s wrist when the client’s arm is hanging down. This allows the client to maintain a slight bend in their elbow when holding the cane.

A. Manifestations of hypoglycemia B. IV insertion site C. The client’s oral intake D. Height of the IV pole

Correct Answer is B

Explanation

Choice A rationale
While manifestations of hypoglycemia are important to monitor in clients receiving insulin or oral hypoglycemic agents, they are not typically a primary concern in clients receiving TPN. TPN solutions contain dextrose, which can actually lead to hyperglycemia if not properly managed.
Choice B rationale

Monitoring the IV insertion site is crucial in clients receiving TPN. Infections and complications can occur at the site of insertion, so regular assessment is necessary. Therefore, Choice B is the correct answer.
Choice C rationale
The client’s oral intake is not a primary concern when receiving TPN, as TPN provides complete nutrition intravenously.
Choice D rationale
The height of the IV pole does not need to be monitored in clients receiving TPN. The infusion pump controls the rate of the TPN infusion.

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A nurse is about to take a client’s oral temperature, but the client has just consumed some ice chips. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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