A nurse is reinforcing teaching with a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? (Select all that apply.)
A client who is drinking Ice water
A client who had recent oral surgery
A client who breaths through the mouth
A client who has hemorrhoids
A client who has a coagulation disorder
Correct Answer : D,E
A. If a client has just consumed ice water, it can lower the oral temperature and lead to inaccurate readings. It's generally recommended to wait at least 15-30 minutes after eating or drinking before taking an oral temperature.
B. A client who has had oral surgery may have swelling, pain, or open wounds, which could make taking an oral temperature uncomfortable and could also lead to inaccurate results. Alternative sites, such as axillary or tympanic, might be preferred.
C. Clients who primarily breathe through their mouth may have a lower oral temperature reading due to airflow affecting the measurement. Additionally, mouth breathing can lead to inaccuracies in the reading.
D. While hemorrhoids themselves do not affect the ability to take an oral temperature, this client is suitable for oral temperature measurement since it does not interfere with the method.
E. A client with a coagulation disorder can typically have their oral temperature taken. There are no contraindications to taking an oral temperature in this case, as long as the client does not have any other conditions affecting their ability to do so.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The Code of Ethics for nurses emphasizes the importance of confidentiality and respecting patient privacy. Accessing a client's medical record without a legitimate reason or involvement in their care violates ethical principles regarding patient rights and privacy.
B. Evidence-based practice involves integrating the best available research with clinical expertise and patient values to inform decision-making. While this standard is important for providing high-quality care, it does not directly relate to the unauthorized access of a client's medical record.
C. Collaboration in nursing refers to working together with other healthcare professionals and the patient to provide coordinated care. While accessing a medical record without involvement in care does not align with collaborative practice, it is not the primary standard being violated in this situation.
D. The quality of practice standard focuses on providing high-quality care and improving patient outcomes. While unethical behavior, such as accessing records without proper justification, could impact quality, this option does not specifically address the violation related to confidentiality and privacy.
Correct Answer is ["A","C","D"]
Explanation
A. Varicella, or chickenpox, is transmitted via airborne transmission. The varicella virus can spread through respiratory droplets and can also linger in the air after an infected person has left the area. Thus, it is included in airborne transmission.
B. Clostridium difficile (C. diff) is primarily transmitted through contact, particularly via contaminated surfaces and the fecal-oral route. It is not considered an airborne disease. Therefore, this option is incorrect.
C. Tuberculosis (TB) is a classic example of a disease transmitted via airborne transmission. TB bacteria are spread through the air when an infected person coughs, sneezes, or talks, allowing the bacteria to remain suspended in the air and be inhaled by others. This option is correct.
D. Rubeola, or measles, is also transmitted via airborne transmission. The measles virus can be spread through respiratory droplets, and the virus can remain airborne for up to two hours after an infected person has left the area. This option is correct.
E. Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA), is primarily transmitted through direct contact with contaminated surfaces or skin, as well as through contact with infected wounds. It is not typically spread through airborne transmission.
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