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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Continuous output from the stoma is expected in patients with an ileostomy. The stoma continuously produces waste, and this is a normal finding.
B: The presence of blood in the stool is an abnormal finding and should be reported immediately. It could indicate bleeding within the gastrointestinal tract, which requires prompt medical evaluation and intervention.
C: Malodorous stool is common with an ileostomy and is not typically a cause for immediate concern. However, if the odor is unusually strong or different, it may warrant further investigation.
D: Liquid consistency of stool is normal for an ileostomy, as the large intestine, which absorbs water, is bypassed. This is not an immediate concern unless there are other symptoms present.
Correct Answer is A
Explanation
A: Having another nurse witness the wasted medication is the correct procedure. This ensures accountability and compliance with regulations regarding the handling and disposal of controlled substances.
B: Returning the wasted medication to the medication dispenser is not appropriate. Once a narcotic has been withdrawn, it cannot be returned to the dispenser due to contamination and safety protocols.
C: Placing the wasted portion of the medication in the sharps container is not correct. Narcotics should be disposed of according to specific protocols, which typically involve witnessing and documentation, not simply placing them in a sharps container.
D: Exiting the medication room to call the health care provider to request an order that matches the dosages is unnecessary. The nurse should follow the proper procedure for wasting the medication with a witness.
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