A nurse is obtaining the temperature of a newborn.
Which of the following sites should the nurse use?

Rectal.

Axillary.

Tympanic.

Oral.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Axillary.

Choice B rationale: The axillary site, or under the arm, is the preferred site for obtaining the temperature of a newborn. This method is safe and generally well-tolerated by infants. It carries a lower risk of injury or discomfort compared to other methods.

Choice A rationale: Rectal temperature measurement can be accurate but is more invasive and may cause discomfort or injury to the newborn. It is generally not the preferred method for routine temperature checks in newborns.

Choice C rationale: Tympanic temperature measurement, which uses the ear canal, may not be accurate for newborns due to their small ear canal size and the presence of vernix caseosa or amniotic fluid.

Choice D rationale: Oral temperature measurement is not suitable for newborns as they cannot hold the thermometer in their mouth safely or reliably. This method is more appropriate for older children and adults.

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Correct Answer is C

Explanation

The correct answer isChoice C.

Choice A rationale:

Encouraging the client to drink low-protein supplements is not the best action. Protein is essential for tissue repair and healing, especially when the body is under stress, such as during radiation therapy. Therefore, it would be more beneficial to encourage high-protein foods and supplements.

Choice B rationale:

Serving the client’s largest meal in the evening is not the most effective strategy. Radiation therapy can cause nausea and vomiting, which are often worse later in the day. Therefore, it might be more beneficial to serve a larger meal earlier in the day when the client is more likely to tolerate it.

Choice C rationale:

Providing the client with cold foods rather than hot foods is the correct action. Hot foods can often exacerbate feelings of nausea, which are common side effects of radiation therapy.Cold foods are generally better tolerated.

Choice D rationale:

Telling the client to drink two glasses of water with meals is not the best advice. While hydration is important, drinking large amounts of fluid with meals can contribute to early satiety, which can further decrease the client’s food intake. It might be more beneficial to encourage the client to drink fluids between meals.

A. Place the client's soiled bed linens in a biohazard bag outside the client's room. B. Wear an isolation gown when caring for the client. C. Keep visitors at least 6 feet (1.8 m) away from the client. D. Discard the radioactive source in the client's trash can.

Correct Answer is C

Explanation

Answer is c. Keep visitors at least 6 feet (1.8 m) away from the client.

a. Place the client's soiled bed linens in a biohazard bag outside the client's room: While it is essential to follow standard precautions for handling potentially contaminated linens, soiled bed linens from a client undergoing brachytherapy do not require special handling in a biohazard bag unless contaminated with blood or bodily fluids. Brachytherapy involves the internal placement of radioactive sources near or within the tumor site, but the risk of contamination from bodily fluids is minimal. Therefore, soiled linens can be managed according to standard facility protocols for handling linens.

b. Wear an isolation gown when caring for the client: This option is incorrect because wearing an isolation gown is not necessary for radiation safety during brachytherapy. Radiation exposure is primarily managed through the use of lead aprons, gloves, and other shielding devices when directly handling radioactive sources or being in close proximity to the client during treatment sessions. Isolation gowns are typically used to prevent the spread of infection and are not specifically designed to shield against radiation exposure.

c. Keep visitors at least 6 feet (1.8 m) away from the client: Correct. This action minimizes radiation exposure to visitors, as brachytherapy involves the internal placement of radioactive material near or within the tumor site. Maintaining a distance of at least 6 feet (1.8 meters) from the client helps reduce the risk of radiation exposure to visitors while allowing them to provide support and companionship to the client. Visitors should also be informed about radiation safety precautions and instructed to limit their time spent near the client during treatment.

d. Discard the radioactive source in the client's trash can: This option is incorrect because radioactive sources used in brachytherapy must be handled and disposed of by trained personnel following established radiation safety protocols. Disposing of radioactive material in a client's regular trash can poses significant risks of exposure to others and is not permitted. Proper disposal procedures for radioactive sources involve packaging them in approved containers and returning them to the facility's radiation safety department for appropriate disposal or recycling.

In summary, the correct answer is c because keeping visitors at least 6 feet (1.8 meters) away from the client helps minimize their radiation exposure during brachytherapy, which involves the internal placement of radioactive material near or within the tumor site. This action aligns with radiation safety principles and helps protect both the client and visitors from unnecessary radiation exposure.

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A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

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A nurse is obtaining the temperature of a newborn.
Which of the following sites should the nurse use?