A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

Wait 30 min and return to measure the oral temperature

Provide the client a sip of warm water, wait 5 min, and measure the temperature.

Document that the nurse was unable to measure the client’s temperature.

Determine if the client has eaten or drank within the last 15 minutes.

Use an alternate route (ie. axillary, rectal) to take the client’s temperature

Answer and Explanation

Correct Answer : B,D,E

A. Wait 30 min and return to measure the oral temperature:

Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.

B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:

This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.

C. Document that the nurse was unable to measure the client’s temperature:

Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route

D. Determine if the client has eaten or drank within the last 15 minutes:

Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.

E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:

If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["2"]

Explanation

To administer the ordered dose of digoxin, you need to calculate how many tablets of the available strength are equivalent to 0.25 mg. You can use the formula:

Ordered dose / Available dose = Number of tablets

Plugging in the values, you get:

0.25 mg / 0.125 mg = 2 tablets

Therefore, you need to administer two tablets of digoxin 0.125 mg to give the ordered dose of 0.25 mg.

A. Take the blood pressure B. Remove the pillow from under the patient’s head C. Elevate the foot of the bed D. Elevate the head of the bed

Correct Answer is A

Explanation

A. Take the blood pressure:

Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.

B. Remove the pillow from under the patient’s head:

Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.

C. Elevate the foot of the bed:

Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.

D. Elevate the head of the bed:

Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Ordered: Digoxin (Lanoxin) 0.25 mg Available: Digoxin (Lanoxin) 0.125 mg per tablet Administer: _____tab(s)

Correct Answer is ["2"]

Explanation

A patient is having dyspnea. What would the nurse do first?

Correct Answer is A

Explanation

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

A nurse is auscultating the breath sounds of a client who has congestive heart failure. When the client exhales, the nurse hears bubbling, popping like sounds. The nurse should document this as which of the following adventitious breath sounds?

A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous. The nurse should apply the pulse oximeter probe to which of the following locations?

Order: Ampicillin (Principen) 150 mg PO every 6 hours Available: Ampicillin (Principen) 125mg per 5 ml How many mL of ampicillin are needed for one dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero. TYPE THE ANSWER ONLY, no label )

Ordered: Potassium chloride (K-Dur) 60 mEq Available: Potassium chloride (K-Dur) 20 mEq/15 mL Administer: _____mL

A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?