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.

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Correct Answer is A

Explanation

A. “I will begin upon the client’s admission to the facility.”

Effective discharge planning should start upon the client's admission to the facility. It is an ongoing process that involves assessing the patient's needs, planning for post-discharge care, and ensuring a smooth transition from the hospital to the next level of care. Early initiation of discharge planning allows the healthcare team to address any potential barriers, educate the patient and their family, and coordinate necessary resources for a successful transition.

B. “I will begin once the client’s insurance company approves discharge coverage.”

Waiting for insurance approval may delay the discharge planning process and hinder the timely coordination of resources needed for post-discharge care.

C. “I will begin 48 hr before the client’s discharge.”

Waiting until 48 hours before discharge may not allow sufficient time to address all aspects of the discharge plan, potentially leading to rushed or incomplete preparations.

D. “I will begin once the client’s discharge order is written.”

Waiting for the discharge order may delay the start of the planning process, and effective discharge planning should be initiated earlier to ensure comprehensive and patient-centered care.

A. Edema B. Heart Rate C. Chills D. Pallor

Correct Answer is C

Explanation

A. Edema:

Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.

B. Heart Rate:

Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.

C. Chills

Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.

D. Pallor:

Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.

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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)

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

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