The nurse must take a patient's rectal temperature. Which should the nurse do?
Take the temperature for 6-8 minutes
Wear gloves throughout the procedure
Place the patient in the prone position
Insert the thermometer 2.5 inches into the patient's anus
The Correct Answer is B
A. Take the temperature for 6-8 minutes. Modern digital thermometers provide accurate readings within seconds to a minute, making such a long duration unnecessary.
B. Wear gloves throughout the procedure. Gloves must be worn to maintain infection control and hygiene, as rectal temperature measurement involves contact with mucous membranes and potential exposure to bodily fluids.
C. Place the patient in the prone position. The left lateral (Sims') position is the preferred position for rectal temperature measurement, as it provides better access and comfort.
D. Insert the thermometer 2.5 inches into the patient's anus. For adults, the correct insertion depth is 1.5 inches (3-4 cm), while for infants, it is only 0.5 inches (1.3 cm) to prevent injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["90"]
Explanation
Calculation:
To convert fluid ounces (FL OZ) to milliliters (mL), the conversion factor is:
1FL OZ = 30mL
Given:
= (3 FL OZ × 30mL)/1 FL OZ
= 90mL
Thus, 3 FL OZ = 90 mL.
Correct Answer is C
Explanation
A. Bradypnea refers to an abnormally slow respiratory rate, typically below 12 breaths per minute in an adult. A rate of 32 breaths/min is too fast to be considered bradypnea.
B. Apnea is the absence of breathing for a prolonged period. Since the patient has a respiratory rate of 32 breaths/min, apnea does not apply.
C. Tachypnea is defined as a rapid respiratory rate exceeding 20 breaths per minute in an adult. A rate of 32 breaths/min indicates tachypnea, which may be caused by conditions such as fever, anxiety, or respiratory distress.
D. Eupnea refers to normal breathing, with a respiratory rate between 12–20 breaths per minute. A rate of 32 breaths/min is too high to be considered eupnea.
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