A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)

Rectal

Urinary Bladder

Temporal Artery

Esophagus

Pulmonary artery

Answer and Explanation

Correct Answer : A,B,D,E

A. Rectal: The rectal route provides a reliable measure of core body temperature because of its proximity to major blood vessels.

B. Urinary Bladder: A temperature-sensing urinary catheter can provide continuous monitoring of core temperature, especially in critical care settings.

C. Temporal Artery: While temporal artery thermometers are non-invasive and commonly used, they measure skin temperature, which is not a true core temperature.

D. Esophagus: Esophageal temperature monitoring is used in intubated patients and cardiac surgery patients to measure core temperature accurately.

E. Pulmonary Artery: A pulmonary artery catheter (Swan-Ganz catheter) directly measures blood temperature from the heart, making it the most accurate core temperature measurement.

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Correct Answer is A

Explanation

A. "Have you had any changes in your diet?" While diet can impact skin health, this question is not the most relevant for an immediate skin assessment. More direct questions about onset, symptoms, and exacerbating factors should be prioritized.

B. "Does your skin condition keep you awake at night?" Pruritus (itching), pain, or discomfort from a skin condition can disrupt sleep. Asking this helps assess the impact on daily life and quality of sleep.

C. "How does your skin condition make you feel?" Skin conditions can affect self-esteem and mental health. This question is therapeutic and appropriate to assess emotional impact.

D. "How do you handle stress?" Many skin conditions, such as eczema and psoriasis, worsen with stress. This question is relevant for identifying triggers.

A. Reads and follows the health care provider's orders. B. Accepts one established way to provide care. C. Makes decisions based on intuition. D. Consider what is important in any given situation.

Correct Answer is D

Explanation

A. Reads and follows the health care provider's orders. While following provider orders is important, critical thinking requires assessing the situation and considering all relevant factors, rather than just following orders without analysis.

B. Accepts one established way to provide care. Critical thinking involves evaluating different approaches and adapting to individual patient needs rather than rigidly adhering to a single method.

C. Makes decisions based on intuition. While intuition can be helpful, evidence-based practice and clinical reasoning should guide decision-making, not just intuition alone.

D. Consider what is important in any given situation. Critical thinking involves analyzing the situation, prioritizing information, and making decisions based on what is most important for patient safety and care.

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A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention?

Correct Answer is A

Explanation

Which action should the nurse take when using critical thinking to make clinical decisions?

Correct Answer is D

Explanation

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