A nurse is teaching a newly licensed nurse about measuring body temperature in clients. Which of the following clients should the nurse instruct to obtain an oral temperature?
A client who has haemorrhoids
A client who had recent oral surgery
A client who has a coagulation disorder
A client who is drinking ice water
The Correct Answer is A
Answer: A
Rationale:
A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.
B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.
C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.
D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client is likely experiencing the acute illness stage of infection, which is characterized by the appearance of specific signs and symptoms of the disease. During this stage, the individual may feel ill and exhibit symptoms such as sneezing, productive cough, muscle aches, headache, and fever.
Correct Answer is A
Explanation
Localized warmth is a classic sign of inflammation and can indicate the presence of an infection or injury in the affected area. Sanguineous drainage is a type of wound drainage that consists of blood and is not a sign of inflammation. Palpable pedal pulses and full range of motion can provide information about the injury, but they are not specific to inflammation. Therefore, options b, c, and d are incorrect.
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