A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Place the tip of the thermometer under the center of the infant's axilla

Pull the pinna of the Infant's ear forward before inserting the probe.

Insert the oral thermometer in front of the infant's tongue.

Insert the probe 3.8 cm (15 in into the infant's rectum

Answer and Explanation

The Correct Answer is A

A. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I should visually monitor the client continuously when in mechanical restraints." Continuous visual monitoring is required to ensure the client’s safety, monitor for distress or injury, and assess the ongoing need for restraints. This is a key safety standard in the use of mechanical restraints.
B. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." Skin integrity must be assessed much more frequently, typically every 15 to 30 minutes, to prevent injury or pressure-related complications while the client is restrained.
C. "I should expect the provider to evaluate the client within 4 hours of restraint application." For adults, a provider must evaluate the client within 1 hour of the initiation of mechanical restraints. A 4-hour delay does not meet safety or legal standards.
D. "I should ask the provider to write a prescription for mechanical restraints as needed." PRN (as-needed) prescriptions for restraints are not permitted. Each use must be justified, time-limited, and based on the client’s immediate behavior or condition.

A. Wear clothing with zippers instead of buttons. B. Place locks at the tops of exterior doors. C. Replace the carpet with hardwood floors. D. Encourage physical activity prior to bedtime.

Correct Answer is B

Explanation

A. Wear clothing with zippers instead of buttons. This may be helpful for caregivers or for promoting independence in dressing, but it does not directly enhance safety in the home for a client with Alzheimer’s disease.
B. Place locks at the tops of exterior doors. Clients with Alzheimer’s are at risk for wandering, especially in later stages. Placing locks at the tops of doors helps prevent elopement while still allowing caregivers to control access, thus enhancing home safety.
C. Replace the carpet with hardwood floors. Carpets can actually provide more traction and cushioning than hardwood, which may be slippery and increase the risk of falls. Removing carpet is not necessary and could reduce safety.
D. Encourage physical activity prior to bedtime. Physical activity is beneficial but should be scheduled earlier in the day, as exercise close to bedtime may increase stimulation and interfere with sleep, which is already often disrupted in Alzheimer’s clients.

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A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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