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 D

Explanation

A: Administering the medication and monitoring the patient frequently is not appropriate because phenytoin is not indicated for pain management.

B: Refusing to give the medication and notifying the nurse supervisor is a step in the right direction, but the nurse should also seek clarification from the health care provider.

C: Giving the patient hydromorphone without clarification is not appropriate. The nurse must verify the order with the health care provider.

D: Calling the health care provider to clarify the order is the correct action. This ensures that the correct medication is administered as intended.

A. Provide the client with a diet high in protein. B. Reposition the client every 3 hours. C. Massage bony prominences to promote circulation. D. Apply cornstarch to keep the skin dry.

Correct Answer is A

Explanation

A: Providing the client with a diet high in protein is essential for maintaining skin integrity. Protein is crucial for tissue repair and regeneration, which helps prevent skin breakdown and promotes healing of existing wounds.

B: Repositioning the client every 3 hours is less effective than the recommended every 2 hours. Frequent repositioning helps to relieve pressure on vulnerable areas and prevent pressure injuries.

C: Massaging bony prominences is not recommended as it can cause further damage to already fragile skin and underlying tissues. Gentle handling and avoiding pressure on these areas are more appropriate.

D: Applying cornstarch to keep the skin dry is not advisable as it can lead to skin irritation and breakdown. Instead, using moisture-wicking products and maintaining proper skin hygiene are better practices.

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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

An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the health care provider meant to write hydromorphone. What should the nurse do?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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