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 B
Explanation
The correct answer is: B. Determine the acuity and number of casualties arriving at the facility.
Choice A rationale: Assisting in discharging stable clients to home is important but not the primary focus during the immediate response to a mass casualty event.
Choice B rationale: Determining the acuity and number of casualties arriving at the facility is crucial in a mass casualty event. This involves assessing the severity of injuries and prioritizing care based on urgency, ensuring that the most critical patients receive immediate attention.
Choice C rationale: Delegating tasks to emergency health care specialists is typically the responsibility of team leaders or incident command staff, not the medical-surgical unit nurses.
Choice D rationale: Providing informational updates to members of the media is generally managed by hospital administration or public relations staff, not by medical-surgical nurses.
Correct Answer is D
Explanation
Choice A rationale:
Referring the client to a nutritionist is not the most appropriate action in this situation. While nutritionists can provide valuable information on infant feeding, the client's primary concern is the inability to afford baby formula. A case manager is better suited to address the client's financial and social needs.
Choice B rationale:
Referring the client to the primary care provider is not the most appropriate action in this situation. The primary care provider may not have the resources or expertise to address the client's financial and social concerns.
Choice C rationale:
Referring the client to a pediatric nurse practitioner is not the most appropriate action in this situation. While pediatric nurse practitioners can provide healthcare for infants, they may not have the resources to address the client's financial constraints.
Choice D rationale:
Referring the client to a case manager is the most appropriate action in this scenario. A case manager can assess the client's financial situation and connect them with appropriate resources, such as government assistance programs or local charities, to help cover the cost of baby formula. Case managers specialize in coordinating care and addressing social determinants of health.
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