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 D

Explanation

Choice A rationale
The deltoid muscle is not typically used for injections in newborns. It is not as developed as the vastus lateralis and does not have as much muscle mass.

Choice B rationale
The ventrogluteal muscle is generally not used for injections in newborns. It is not as accessible or as well developed as the vastus lateralis.
Choice C rationale
The dorsogluteal muscle is not recommended for injections in newborns due to the risk of damaging the sciatic nerve.
Choice D rationale
The vastus lateralis muscle is the preferred site for intramuscular injections in newborns. It is the most developed muscle in this age group and is free of major nerves and blood vessels.

A. There is slough on part of the wound area. B. There appears to be persistent reddening of the skin. C. There is full-thickness skin loss with a crater. D. There is a fluid-filled area under the skin.

Correct Answer is C

Explanation

Choice A rationale
Slough, which is a layer of yellowish, dead tissue that can develop on the surface of a wound, is not a defining characteristic of a stage 3 pressure ulcer.
Choice B rationale
Persistent reddening of the skin is typically associated with a stage 1 pressure ulcer, not a stage 3. In a stage 1 pressure ulcer, the skin remains intact but may be red and may not blanch (lose color briefly) when you press your finger on it.
Choice C rationale
A stage 3 pressure ulcer involves full-thickness skin loss that appears as a deep crater. The ulcer may extend into the subcutaneous tissue layer, but not through it to the underlying

muscle or bone. This description matches the statement in Choice C, making it the correct answer.
Choice D rationale
A fluid-filled area under the skin could potentially indicate a blister or a stage 2 pressure ulcer, not a stage 3. In a stage 2 pressure ulcer, the outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) are damaged or lost.

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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 is preparing to administer vitamin K intramuscularly to a newborn. Which of the following muscles should the nurse use for the injection?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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