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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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. “I will place a bath seat in my shower to use when I bathe.”. B. “I will keep the fluorescent ceiling light on in my room at night.”. C. “I will place an area rug at the entry of my bathroom.”. D. “I will keep my walker at the end of my bed.”. .

Correct Answer is A

Explanation

Choice A rationale
Placing a bath seat in the shower is a good safety measure for a patient with a history of falls. It allows the patient to sit while bathing, reducing the risk of slipping and falling.
Choice B rationale

Keeping the fluorescent ceiling light on in the room at night can actually increase the risk of falls. It can create shadows and glare that can be disorienting, especially for older adults.
Choice C rationale
Placing an area rug at the entry of the bathroom is not recommended. Rugs can easily become tripping hazards, especially if they’re not secured to the floor.
Choice D rationale
Keeping a walker at the end of the bed can be helpful for some patients, but it’s not the best indication that the patient understands home safety instructions. It’s important that the walker is used correctly and that the patient’s home is arranged to accommodate its use.

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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

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about the use of assistive devices during client ambulation. Which of the following instructions should the nurse include about assisting clients who use a cane?

Correct Answer is B

Explanation

A nurse is reinforcing home safety instructions for a patient with a history of falls. Which statement should the nurse identify as an indication that the patient understands the instructions?

Correct Answer is A

Explanation

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