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 minutes, and measure the temperature.

Wait 30 minutes 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 eaten ice chips is not appropriate. The cold temperature can affect the accuracy of the reading.

B: Documenting that the nurse was unable to measure the client’s temperature is unnecessary. The nurse can take steps to ensure an accurate measurement by waiting.

C: Providing the client a sip of warm water and waiting 5 minutes is not sufficient to counteract the effect of the ice chips on the oral temperature reading.

D: Waiting 30 minutes before measuring the oral temperature is the correct action. This allows time for the oral cavity to return to its normal temperature, ensuring an accurate reading.

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Correct Answer is A

Explanation

A: Checking the display on the PCA pump is the first action the nurse should take. This ensures that the pump is functioning correctly and delivering the prescribed dose of medication. It helps identify any technical issues that may be affecting pain control.

B: Obtaining an order for another pain medication for breakthrough pain is important if the current regimen is insufficient. However, this should follow the initial assessment of the PCA pump’s functionality.

C: Administering a bolus of medication may be necessary if the client is experiencing severe pain, but it should be done after confirming that the PCA pump is working correctly.

D: Encouraging the client to administer a demand dose is appropriate if the PCA pump is functioning correctly. However, the nurse should first verify that the pump is delivering the medication as prescribed.

A. “I will keep the fluorescent ceiling light on in my room at night.” B. “I will keep my walker at the end of my bed.” C. “I will place a bath seat in my shower to use when I bathe.” D. “I will place an area rug at the entry of my bathroom.”

Correct Answer is C

Explanation

A: Keeping a fluorescent ceiling light on at night can be too bright and disrupt sleep. A nightlight is a better option for safety without disturbing sleep.

B: Keeping the walker at the end of the bed is not ideal. The walker should be within easy reach to prevent falls when getting out of bed.

C: Placing a bath seat in the shower is a good safety measure. It provides stability and reduces the risk of slipping and falling while bathing.

D: Placing an area rug at the entry of the bathroom can be a tripping hazard. It is better to use non-slip mats that are securely placed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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