A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Proceed to measure the oral temperature.

Document that the nurse was unable to measure the client's temperature.

Provide the client a sip of warm water, wait 5 min, and measure the temperature.

Wait 30 min and return to measure the oral temperature.

Answer and Explanation

The Correct Answer is D

A. Proceeding to measure the oral temperature immediately after the client has consumed ice chips can lead to an inaccurate reading due to the cooling effect of the ice.

B. Documenting that the nurse was unable to measure the client's temperature is unnecessary; it is possible to obtain an accurate measurement after a suitable waiting period.

C. Providing a sip of warm water will not resolve the issue of the ice chips affecting the temperature reading, as the nurse should still wait a longer period for accuracy.

D. Waiting 30 minutes after the client has consumed ice chips is the best practice, as it allows sufficient time for the oral cavity to return to a baseline temperature for an accurate measurement.

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Correct Answer is A

Explanation

A. Checking the client for allergies is the first step in ensuring the safety of medication administration; it is crucial to verify that the client does not have any known allergies to the medication before proceeding.

B. Documenting that the medication was administered should occur after the medication has been given, not before.

C. Mixing the medication at the client’s bedside is an important step, but it should be done only after confirming that the medication is appropriate for the client.

D. Determining the client's response to the medication occurs after administration, making it a follow-up action rather than a first step.

A. Give the medication. B. Return the medication to the pharmacy. C. Discard the medication. D. Notify the provider.

Correct Answer is C

Explanation

A. Giving the medication that is expired poses a risk to the client, as the safety and efficacy of the medication cannot be guaranteed past its expiration date.

B. Returning the medication to the pharmacy may not be feasible in this scenario; proper disposal is generally the nurse's responsibility for expired medications.

C. Discarding the medication is the appropriate action to ensure client safety, as expired medications should not be administered.

D. Notifying the provider is unnecessary in this case; the nurse's responsibility is to discard the expired medication and prepare a new dose that is within its expiration date.

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