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:
Improved respiratory function is incorrect. Pancrelipase primarily helps with the digestion and absorption of fats and fat-soluble vitamins. It does not directly impact respiratory function. Respiratory improvement in cystic fibrosis typically involves treatments such as airway clearance techniques, bronchodilators, and antibiotics to manage lung infections.
Choice B Reason:
Reduced fat in the stools is correct. Pancrelipase is an enzyme replacement therapy used to treat individuals with cystic fibrosis, a condition that affects the pancreas's ability to produce digestive enzymes. Cystic fibrosis leads to the malabsorption of nutrients, especially fats. Pancrelipase supplements these digestive enzymes and helps the child digest and absorb fat properly. As a result, one of the expected therapeutic effects of pancrelipase is a reduction in fat in the stools, as the enzymes aid in the digestion of dietary fats, leading to improved absorption of nutrients. This, in turn, can help address malnutrition and promote overall health in individuals with cystic fibrosis.
Choice C Reason:
Improved absorption of vitamins B and C is incorrect. While pancrelipase can help with the absorption of fat-soluble vitamins (A, D, E, and K), it does not directly affect the absorption of vitamins B and C, which are water-soluble vitamins. Cystic fibrosis primarily affects the absorption of fat-soluble vitamins due to impaired fat digestion.
Choice D Reason:
Decreased sodium excretion is incorrect. Cystic fibrosis is associated with excessive loss of salt (sodium chloride) in sweat. Pancrelipase does not directly affect sodium excretion. Treatment for managing sodium loss typically involves salt supplementation and ensuring proper hydration.
Correct Answer is C
Explanation
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.
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