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 C

Explanation

A: Identifying the type of sedative is important for treatment but is not the immediate priority.

B: Inserting a large-bore IV catheter is necessary for administering medications and fluids but is not the first priority.

C: Ensuring an adequate airway is the priority action. Maintaining airway patency is crucial to prevent respiratory complications and ensure the client receives adequate oxygen.

D: Preparing the appropriate antagonist is important but should follow the immediate action of ensuring an adequate airway.

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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