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
Locking the wheels of the bed and the wheelchair is an important safety measure when assisting a client to move from the bed to a wheelchair. However, this action alone is not sufficient. The nurse also needs to ensure the client’s safety during the transfer by using proper body mechanics and providing adequate support.
Choice B rationale
Elevating the bed to a position of comfort for the nurse is the correct action. This helps to ensure that the nurse can maintain proper body mechanics during the transfer, reducing the risk of injury to both the nurse and the client.
Choice C rationale
Getting the help of several staff members to lift the client is not typically necessary when transferring a client with generalized weakness from the bed to a wheelchair. With proper positioning and technique, one nurse can often safely assist the client with this type of transfer.
Choice D rationale
Placing the wheelchair at a 90° angle to the bed is not the recommended position when transferring a client from the bed to a wheelchair. Instead, the wheelchair should be positioned parallel to the bed or at a slight angle.

A. Turn the patient on their side before starting oral care. B. Apply petroleum jelly to the patient’s lips after oral care. C. Use the thumb and index finger to keep the patient’s mouth open. D. Use a stiff toothbrush to clean the patient’s teeth.

Correct Answer is A

Explanation

Choice A rationale
Turning the patient on their side before starting oral care is a recommended practice when caring for an unresponsive patient. This position helps prevent aspiration, which can occur if the patient cannot swallow properly.
Choice B rationale
Applying petroleum jelly to the patient’s lips after oral care can help prevent dryness and cracking. However, it’s not the primary action the nurse should take when performing oral hygiene for an unresponsive patient.
Choice C rationale
Using the thumb and index finger to keep the patient’s mouth open is not recommended. It can cause discomfort and potential injury to the patient.
Choice D rationale
Using a stiff toothbrush to clean the patient’s teeth is not recommended. A soft toothbrush is usually used to clean the teeth of an unresponsive patient to prevent damage to the gums.

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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 assisting a client who has generalized weakness to move from the bed to a wheelchair. What actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a long-term care facility is taking care of a patient who is unresponsive. What action should the nurse take when performing oral hygiene for the patient?

Correct Answer is A

Explanation

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