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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Herpes simplex is primarily transmitted through direct contact with the skin or mucous membranes of an infected individual. Contact precautions are designed to prevent the spread of microorganisms that are transmitted by direct contact or indirect contact with contaminated surfaces. These precautions include wearing gloves and a gown when entering the client's room, ensuring proper hand hygiene, and using dedicated equipment for the client.

Droplet precautions are used for infections that are transmitted through respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis.

Airborne precautions are used for infections that are transmitted by smaller droplet nuclei that can remain suspended in the air for longer periods, such as tuberculosis or measles.

Protective environment is a specialized isolation precaution used for clients with compromised immune systems, such as those undergoing stem cell transplantation, and involves strict control of the environment to reduce the risk of acquiring infections.

A. "I might have occasional seizures for several days after the procedure." B. "I might have short-term memory loss after the procedure." C. "I will have a urinary catheter in place during the procedure." D. "I will need to follow a full-liquid diet for 24 hours after the procedure."

Correct Answer is B

Explanation

Choice A Reason:

"I might have occasional seizures for several days after the procedure." This statement is not accurate. ECT does induce a controlled seizure during the procedure, but clients typically do not experience seizures after the treatment. This statement does not indicate an understanding of the procedure.

Choice B Reason:

"I might have short-term memory loss after the procedure. “This statement is accurate. Memory loss is a common side effect of ECT, particularly short-term memory loss. It's important for the client to be aware of this potential side effect.

Choice C Reason:

"I will have a urinary catheter in place during the procedure." This statement is not accurate. A urinary catheter is not typically used during ECT. It's important for the client to have accurate information about the procedure.

Choice D Reason:

"I will need to follow a full-liquid diet for 24 hours after the procedure." This statement is not accurate. Clients undergoing ECT do not usually require a full-liquid diet afterward. The dietary restrictions may vary depending on the facility's policies, but it is not typically a full-liquid diet.

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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?

Nursing Test Bank

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