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 ["2.0"]
Explanation
Step 1: Determine the dosage required. 20 mEq
Step 2: Determine the concentration of the suspension. 10 mEq per mL
Step 3: Calculate the volume needed. 20 mEq ÷ 10 mEq per mL = 2 mL
The nurse should administer 2.0 mL per dose.
Correct Answer is D
Explanation
A: Degenerative joint changes can affect mobility and overall health but do not directly contribute to aspiration pneumonia.
B: Decreased gastric secretions can affect digestion but are not a primary factor in the development of aspiration pneumonia.
C: A decreased sense of smell can affect appetite and food intake but does not directly lead to aspiration pneumonia.
D: A diminished cough reflex is a significant age-related change that can contribute to the development of aspiration pneumonia. The cough reflex helps clear the airway of food, liquid, and other foreign materials. When this reflex is diminished, the risk of aspiration and subsequent pneumonia increases.
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