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 points the probe posteriorly.
The AP pulls the pinna up and back.
The AP positions the client facing her.
The Correct Answer is C
The correct answer is: c. The AP pulls the pinna up and back.
Choice A reason: The AP inserting the probe with a straight, forward motion is not the correct technique for tympanic temperature measurement. The ear canal does not run straight forward into the head; instead, it curves slightly. Inserting the probe straight forward could potentially damage the ear canal or eardrum and would not provide an accurate temperature reading.
Choice B reason: Pointing the probe posteriorly is also incorrect. The tympanic membrane is located at the end of the ear canal, and the probe should be directed towards it. However, the probe should be angled slightly downward and toward the jawline, not straight back, to align with the ear canal and ensure an accurate reading.
Choice C reason: Pulling the pinna up and back is the correct method for adults and children over one year old. This action straightens the ear canal, allowing the thermometer’s sensor to get a clear path to the tympanic membrane, which is necessary for an accurate temperature reading. For infants, the correct method is to pull the earlobe straight back.
Choice D reason: The AP positioning the client facing her does not directly relate to the technique of measuring tympanic temperature. While it may be necessary for the AP to see the client’s ear, it is not an indication of understanding the correct procedure for tympanic temperature measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Reporting a penicillin allergy in the client's history is essential when the client is prescribed cefaclor. Cefaclor is a cephalosporin antibiotic, and individuals with a documented penicillin allergy may have an increased risk of cross-reactivity and allergic reactions to cephalosporin antibiotics. Therefore, it is crucial to report a penicillin allergy to the provider to evaluate the potential risks and consider alternative antibiotics if necessary.
Choice B rationale:
An egg allergy is not directly relevant to the prescription of cefaclor. While allergies to various substances can be important in healthcare, egg allergy is not a contraindication or concern when prescribing cefaclor. Therefore, it does not require specific reporting in this context.
Choice C rationale:
Tendonitis is not directly related to the prescription of cefaclor. Tendonitis is an inflammatory condition affecting tendons and is not typically a contraindication for cefaclor or other cephalosporin antibiotics.
Correct Answer is A
Explanation
Choice A rationale:
"Determine the client's ability to use the call light." - This is the correct answer. Assessing the client's ability to use the call light is the first step in fall prevention. If the client can effectively use the call light, they can request assistance when needed, reducing the risk of falls. It's essential to assess their communication and mobility abilities.
Choice B rationale:
"Create a schedule with an assistive personnel to do hourly rounding for the client." - While hourly rounding is a valuable fall prevention strategy, assessing the client's ability to use the call light should be the initial step to ensure immediate access to help. Rounding can complement this measure.
Choice C rationale:
"Move the bedside table with the client's personal items close to the bed." - While ensuring the client's personal items are within reach is important for their comfort and convenience, it is not the first step in fall prevention. Assessing the client's ability to request assistance takes precedence.
Choice D rationale:
"Apply rubber-soled slippers before ambulation." - Providing appropriate footwear is important for fall prevention, but it is not the first precaution to implement. Assessing the client's ability to use the call light and communicate their needs comes before addressing ambulation.
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