A nurse is in the process of taking a patient’s oral temperature.
The patient informs the nurse that they have just consumed some ice chips. What should the nurse do next?
Record that the nurse was unable to take the patient’s temperature.
Continue to take the oral temperature.
Wait for 30 minutes and then return to take the oral temperature.
Give the patient a sip of warm water, wait for 5 minutes, and then take the temperature.
The Correct Answer is C
Choice A rationale
Recording that the nurse was unable to take the patient’s temperature would not be the most appropriate action in this situation. The nurse can wait for a certain period of time and then take the patient’s temperature.
Choice B rationale
Continuing to take the oral temperature immediately after the patient has consumed ice chips could result in an inaccurately low temperature reading. The cold from the ice chips can temporarily lower the temperature in the mouth.
Choice C rationale
Waiting for 30 minutes and then returning to take the oral temperature is the most appropriate action. Consuming cold substances can lower the oral temperature temporarily, so it’s recommended to wait 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Choice D rationale
Giving the patient a sip of warm water, waiting for 5 minutes, and then taking the temperature is not the standard procedure. While it might help to normalize the temperature in the mouth more quickly, it’s generally recommended to wait at least 15-30 minutes after the patient has consumed something cold before taking an oral temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The statement “Our car seat is an infant model and is anchored in the car” indicates a correct understanding of car seat safety. Infant car seats are specifically designed to protect infants during a collision. They are rear-facing seats, which is the safest position for an infant because it provides the most support for the infant’s head, neck, and spine. Anchoring the car seat in the car is crucial as it ensures the seat stays in place during a collision.
Choice B rationale
The statement “The car seat is rear-facing in the front passenger seat” is incorrect. It is not safe to place a rear-facing car seat in the front passenger seat of a vehicle. In the event of a collision, an airbag can deploy and hit the car seat, causing serious injury to the infant.
Choice C rationale
The statement “I can fit my hand between the baby and the car seat harness” is incorrect. The harness of a car seat should be snug against the baby’s body. If you can fit your hand between the baby and the harness, it means the harness is too loose, which can be dangerous in the event of a collision.
Choice D rationale
The statement “Our car seat is front-facing in the back seat” is incorrect. Infants should always be in a rear-facing car seat until they reach the highest weight or height allowed by their car safety seat’s manufacturer.
Correct Answer is D
Explanation
When caring for a patient who practices Islam, the nurse should request a meal tray without pork. Dietary laws in Islam, known as halal, prohibit the consumption of pork.
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