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","B","C","E"]
Explanation
A. Diversity, which emphasizes the importance of inclusivity and respect for the varied backgrounds and perspectives within the nursing community.
B. Professionalism is another key value, highlighting the need for integrity, responsibility, and excellence in the nursing profession.
C. Advocacy is also central to the NSNA's ethical framework, as it involves working on behalf of others to promote health and well-being.
D. While Safety is a crucial aspect of nursing practice, it is not explicitly listed as part of the NSNA's core values according to the information available.
E. Quality Education is recognized as a fundamental value, ensuring that student nurses receive the knowledge and training necessary to provide high-quality care.
F. While confidentiality is a crucial aspect of nursing practice, it is not explicitly listed as part of the NSNA's core values according to the information available.
Correct Answer is A
Explanation
A. The planning step involves setting goals and determining appropriate interventions to achieve desired outcomes for the client. During this phase, the nurse collaborates with the healthcare team, including
the RN, to establish measurable and realistic goals tailored to the client’s needs.
B. This step refers to the execution of the planned interventions. It involves carrying out the nursing actions and strategies that were developed during the planning phase. While important, implementation is not the stage where goals are formulated.
C. Evaluation is the step where the nurse assesses the effectiveness of the interventions and whether the goals have been met. This phase involves reviewing the client’s progress and determining if adjustments are needed for the care plan. Formulating goals occurs prior to this step.
D. This step is part of the assessment phase, where the nurse gathers information about the client’s health status, history, and needs. While data collection is essential for informing the planning process, it does not involve the formulation of goals.
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