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 C

Explanation

A. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario.

B. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary.

C. Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving.

D. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed. B. Asking the patient what pain-relief methods, pharmacological and nonpharmacological approach have worked best in the past? C. Administering pain-relief medication according to what was given last shift. D. Offering pain-relief medications based on the providers orders.

Correct Answer is B

Explanation

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed. Pain is subjective and should always be believed and assessed rather than dismissed based on procedure type. This does not demonstrate critical thinking.

B. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked best in the past. This approach assesses the patient’s individual experience and applies personalized care, which is a hallmark of critical thinking.

C. Administering pain-relief medication according to what was given last shift. Pain levels fluctuate, and medication effectiveness must be reassessed each time. Simply repeating the previous shift’s orders does not involve critical thinking.

D. Offering pain-relief medications based on the provider’s orders. While following orders is necessary, critical thinking involves assessing the patient’s pain level and determining the most appropriate intervention rather than blindly administering medication.

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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.)

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