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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Memory loss that disrupts activities of daily living (ADLs) is a common manifestation of dementia, which is a progressive decline in cognitive function. Pressured speech, catatonia, and illusions are more likely to be seen in clients who have psychotic disorders, such as schizophrenia or bipolar disorder.
Correct Answer is D
Explanation
The correct answer is D.
Reduced fat in the stools. Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas, which are lacking in most people with cystic fibrosis due to excess mucus production that clogs the pancreatic ducts. By taking pancrelipase, the child can improve their digestion of food and absorb more nutrients, especially fat and fat-soluble vitamins. This will result in reduced fat in the stools, which is a sign of pancreatic insufficiency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today