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 D
Explanation
Choice A rationale:
Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.
Choice B rationale:
Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.
Choice C rationale:
Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.
Choice D rationale:
Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.
Correct Answer is ["7.5"]
Explanation
To calculate the amount of carbamazepine suspension needed for each dose, you can use the following formula: (Dose required in mg / Concentration available in mg/mL) = Volume to administer in mL In this case: (150 mg / 100 mg/5 mL) = Volume to administer in mL (150 mg / 20 mg/mL) = 7.5 mL Therefore, the nurse should administer 7.5 mL of carbamazepine suspension via the NG tube for each dose.
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