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 A

Explanation

Choice A Reason:

Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.

Choice B Reason:

Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.

Choice C Reason:

Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.

Choice D Reason:

Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.

A. Administer an oral contrast solution. B. Inform the client the procedure will take 60 min. C. Ensure that the client's bladder is full. D. Ensure that the client gave informed consent.

Correct Answer is D

Explanation

Informed consent is a critical step before any invasive procedure, including an EGD. The nurse should confirm that the client has received the necessary information about the procedure, its risks and benefits, and has given their consent voluntarily. This ensures that the client understands the procedure and its implications, making it an essential part of their rights and safety.

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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?

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