A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?
The AP inserts the probe with a straight, forward motion.
The AP positions the client facing her.
The AP pulls the pinna up and back.
The AP points the probe posteriorly.
The Correct Answer is C
Choice A Reason:
Inserting the probe with a straight, forward motion is not correct because the ear canal is curved, and this technique could lead to inaccurate readings or discomfort.
Choice B Reason:
The AP positions the client facing her. The position of the client's face is not relevant to taking a tympanic temperature. The client can face any direction during the procedure.
Choice C Reason:
Pulling the pinna up and back straightens the ear canal in adults, allowing for a more accurate reading when taking a tympanic temperature.
Choice D Reason:
Pointing the probe posteriorly is incorrect as the probe should be pointed towards the tympanic membrane, which usually requires slight angling to align with the ear canal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Documenting the administration of medications after all assigned clients have been medicated is generally a good practice but doesn't address medication safety directly.
Choice B Reason:
Checking the clients' allergy bands with each medication administration is correct. During a review of medication administration protocol, it is important to emphasize safety practices that help prevent medication errors and ensure the correct medication is administered to the right patient. Checking the clients' allergy bands with each medication administration is a crucial safety step to verify the patient's identity and confirm allergies. This practice helps prevent medication errors related to patient identification and allergies.
Choice C Reason:
Reading medication labels twice before administration is an important practice, but it's not specific to patient identification or allergy checking.
Choice D Reason:
Using one client identifier before administering medication is important, but it's just one aspect of ensuring patient identification. Checking allergy bands provides an additional layer of safety by confirming allergies, which can be crucial in preventing adverse reactions.
Correct Answer is C,A,D,B
Explanation
Verify that the provider has certified the client's death: Before any postmortem care is initiated, it's crucial to confirm that the client has indeed passed away. This verification is typically done by a healthcare provider, such as a physician or nurse practitioner, who examines the client, checks for signs of life, and makes an official declaration of death.
Determine the family's preferences about care of the body: After the client's death has been certified, the healthcare team should communicate with the family or next of kin to inquire about their preferences regarding the care of the deceased. Families may have specific cultural, religious, or personal requests regarding postmortem care procedures, and it's essential to respect and accommodate these preferences whenever possible.
Remove all equipment and tubes from the client's body: This step involves the removal of any medical equipment, devices, or tubes that may have been in use during the client's medical care. This can include items such as intravenous (IV) lines, catheters, ventilator tubing, and monitoring equipment. Ensuring that all equipment is removed is not only a matter of dignity but also helps prepare the body for viewing by the family, if desired.
Apply identifying name tags onto the client .To maintain accurate identification and tracking of the deceased client, it's common practice to attach identifying name tags or labels to the body. These tags typically contain essential information, such as the client's name, medical record number, and date of birth. This step helps prevent any confusion or mix-up of identities during postmortem procedures and transport.
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