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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

"Request an x-ray of the preschooler's neck." - This action is not indicated for a preschooler with manifestations of respiratory syncytial virus (RSV) RSV primarily affects the respiratory system, and an x-ray of the neck would not be relevant for this condition.

Choice B rationale:

"Initiate droplet precautions." - This is the correct answer. RSV is highly contagious and primarily spreads through respiratory droplets. Initiating droplet precautions, such as wearing a mask and practicing proper hand hygiene, is essential to prevent the transmission of the virus to others in the healthcare setting.

Choice C rationale:

"Administer fluconazole to the preschooler." - Fluconazole is an antifungal medication and would not be appropriate for treating RSV, which is a viral respiratory infection. Antifungal medications are used to treat fungal infections, not viral ones.

Choice D rationale:

"Monitor the preschooler's urine for protein." - Monitoring urine for protein is not relevant to the care of a preschooler with RSV. This action is more suitable for conditions that may affect the kidneys or urinary system but not RSV, which primarily affects the respiratory system.

A. Hegar's sign. B. Chloasma. C. Ballottement. D. Chadwick's sign.

Correct Answer is D

Explanation

Choice A rationale:

Hegar's sign is a softening of the uterine isthmus, which occurs during early pregnancy. It is not related to changes in the color of the vagina and vulva.

Choice B rationale:

Chloasma refers to the appearance of dark, blotchy, and hyperpigmented skin patches that can occur during pregnancy, primarily on the face. It is not related to changes in the color of the vagina and vulva.

Choice C rationale:

Ballottement is a technique used during a physical examination to assess for a floating fetus within the amniotic fluid. It is not related to changes in the color of the vagina and vulva.

Choice D rationale:

Chadwick's sign is the purplish or bluish discoloration of the vaginal and vulvar mucosa that can occur during pregnancy. This sign is due to increased blood flow to the area, which is a normal physiological change in pregnancy.

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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

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus.Which of the following actions should the nurse take?

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Explanation

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Correct Answer is D

Explanation

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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?