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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. The client is receiving an oxygen concentration of 28%. Nasal cannulas can deliver oxygen at a flow rate ranging from 1 to 6 liters per minute (L/min), with
each additional liter increasing the fraction of inspired oxygen (FiO2) by 4%. Therefore, at 2 L/min, the client is receiving an oxygen concentration of 28%78.
Correct Answer is A
Explanation
Choice A rationale
Vibration is a technique used in chest physiotherapy to increase the turbulence of the client’s exhaled air. It involves the use of manual or mechanical techniques to create vibrations in the chest wall during exhalation. This helps to loosen mucus in the airways and improve clearance of secretions.
Choice B rationale
Percussion, also known as chest clapping, is a technique used in chest physiotherapy to help loosen and mobilize secretions in the lungs. However, it does not specifically increase the turbulence of exhaled air.
Choice C rationale
Postural drainage involves positioning the client in specific ways to use gravity to assist in the removal of secretions from the lungs. While it can be beneficial in managing respiratory infections, it does not directly increase the turbulence of exhaled air.
Choice D rationale
Nebulization involves the use of a machine to create a mist of medication that the client inhales into the lungs. While it can be used to deliver medications to help manage respiratory infections, it does not increase the turbulence of exhaled air.
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