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 straightforward 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

The correct answer is choice C. The AP pulls the pinna up and back.

Choice A rationale:

Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.

Choice B rationale:

Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.

Choice C rationale:

Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.

Choice D rationale:

Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.

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Correct Answer is A

Explanation

The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.

A. Lower the client's bed to the lowest position. B. Stand next to the client's shoulders. C. Place a small pillow under the client's head. D. Flex his hips while pulling the client.

Correct Answer is D

Explanation

The correct answer is D.

Flex his hips while pulling the client. The nurse and AP should use proper body mechanics when repositioning a client to prevent injury and promote comfort. Flexing the hips while pulling the client reduces strain on the back muscles and allows for greater leverage.

The nurse and AP should raise the bed to a comfortable working height, not lower it to the lowest position. The nurse and AP should stand on opposite sides of the bed near the client's hips, not shoulders. The nurse and AP should remove any pillows under or around the client before repositioning him.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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