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 C
Explanation
Rationale:
A. "This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. Teaching should focus on bleeding risks and precautions rather than unrelated symptoms.
B. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption. The main dietary consideration is maintaining consistent vitamin K intake, as large fluctuations can alter anticoagulation.
C. "Use an electric razor when shaving while taking this medication.": Warfarin increases the risk of bleeding and bruising. Using an electric razor reduces the chance of cuts, promoting safety during routine grooming.
D. "Avoid prolonged exposure to sunlight while taking this medication.": Sun exposure is not contraindicated with warfarin; there is no significant interaction between warfarin and UV light.
Correct Answer is A
Explanation
Rationale:
A. "The nurse will ask you to remove any transdermal patches prior to the procedure.": Some transdermal patches contain metallic components that can overheat during an MRI, posing a burn risk. Removing them prevents injury and ensures safety in the strong magnetic field.
B. "The nurse will ask you to wear protective eyewear during this procedure.": Protective eyewear is not necessary for MRI scans, as there is no exposure to bright light or flying debris. This precaution applies more to procedures involving lasers or potential eye hazards.
C. "You should not have this procedure if you are allergic to iodine.": Iodine allergies are a concern with certain CT scans using iodinated contrast, not standard MRIs. MRI contrast agents typically contain gadolinium, which has a different allergy profile.
D. "You should not have this procedure if you have a tattoo.": Tattoos generally do not contraindicate MRI, although some with metallic ink may cause mild skin irritation. This is rare and does not usually prevent the procedure from being performed.
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