A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?
Pull the pinna of the infant's ear forward before inserting the probe.
Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
Place the tip of the thermometer under the center of the infant's axilla.
Insert the oral thermometer in front of the infant's tongue.
The Correct Answer is C
Rationale:
A. Pull the pinna of the infant's ear forward before inserting the probe: For infants, the pinna should be pulled down and back, not forward, to align the ear canal properly for accurate tympanic temperature measurement.
B. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal insertion for infants should be limited to 2.5 cm (1 in) or less to avoid rectal perforation and injury. Inserting 3.8 cm is unsafe.
C. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature measurement is safe and commonly used in infants. Placing the tip in the center of the axilla and holding the arm snugly ensures accurate contact and reading.
D. Insert the oral thermometer in front of the infant's tongue: Infants cannot reliably hold a thermometer under their tongue, making oral measurement inaccurate and unsafe due to risk of swallowing or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Check the cords of the IV pump for fraying: Inspecting electrical cords for fraying or damage is an important safety step before use. Damaged cords can cause electrical shock, fire hazards, or equipment malfunction, so this helps ensure safe operation.
B. Remove the safety inspection sticker before plugging in the IV pump: Safety inspection stickers indicate that the device has passed electrical and functional safety checks. Removing them would eliminate visible proof of inspection and is not necessary for safe use.
C. Ensure that the electric outlet has two prongs for the IV pump: Medical equipment such as IV pumps should be plugged into grounded three-prong outlets to reduce the risk of electrical shock. Two-prong outlets do not provide this grounding protection.
D. Grasp the IV pump cord when unplugging it from the electrical outlet: Pulling on the cord can damage the internal wires and increase the risk of electrical hazards. The correct method is to grasp the plug itself when disconnecting from the outlet.
Correct Answer is D
Explanation
Rationale:
A. "I allow myself 10 minutes to finish each client's dressing change.": Assigning a fixed time to every procedure may not be realistic, as dressing change complexity and patient needs can vary. Overly rigid timing can compromise quality of care and flexibility in prioritizing tasks.
B. "I try to be working on at least three tasks at once so I can finish on time.": Multitasking in nursing can lead to errors, incomplete documentation, and compromised patient safety. Prioritizing and completing tasks sequentially is more effective for accuracy and quality care.
C. "I do not document my interventions in the electronic medical records until the end of each shift.": Delayed documentation increases the risk of errors, omissions, and inaccurate reporting. Timely documentation is essential for continuity of care and legal accuracy.
D. "I perform stat and time-critical care as soon as I receive the provider's prescriptions.": Addressing urgent and time-sensitive tasks immediately ensures that critical needs are met without delay. This reflects appropriate prioritization and effective time management.
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