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 B

Explanation

A. Trying to defecate at different times of the day may not be effective; it's better to establish a regular bowel routine.

B. Increasing daily fluid intake is correct, as adequate hydration helps soften stool and promote regular bowel movements, making it an essential part of managing constipation.

C. Reducing daily activity is incorrect; regular physical activity can stimulate bowel function and alleviate constipation.

D. Consuming a low-fiber diet is not advisable, as a high-fiber diet is recommended for preventing and managing constipation by promoting healthy bowel movements.

A. Discard the tablet and obtain another dose of medication. B. Use the tablet's packaging to pick it up from the counter. C. Wash the tablet off with alcohol and place it in a clean medication cup. D. Place the tablet directly into a medication cup.

Correct Answer is A

Explanation

A. Discarding the tablet and obtaining another dose is the safest option, as it ensures the medication's integrity and prevents any potential contamination.

B. Using the tablet's packaging to pick it up is not appropriate as it could introduce contaminants from the surface of the counter to the tablet.

C. Washing the tablet with alcohol is not advisable because it could alter the medication's properties or effectiveness.

D. Placing the tablet directly into a medication cup without addressing its contamination would also be inappropriate and could jeopardize client safety.

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Nursing Test Bank

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