The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.
Which action should the nurse implement?
Remind the UAP to locate the thermometer before gently inserting the ear.
Demonstrate the correct technique for pulling the client's auricle up and back.
Advise the UAP to hold the thermometer securely in place to obtain the measurement.
Use positive reinforcement to affirm that the procedure being performed correctly.
The Correct Answer is D
The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.
Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.
Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.
Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Placing a client in restraints without having a healthcare provider’s order.
It is inappropriate for a nurse to place a client in restraints without having a healthcare provider’s order.
Choice B is not the answer because administering the medication to a client behind a closed curtain is not necessarily inappropriate.
Choice C is not the answer because enlisting security personnel to assist with restraining the client may be necessary in some situations.
Choice D is not the answer because informing a client that the medication being administered is a sedative is not necessarily inappropriate.
Correct Answer is B
Explanation
The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.
According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.
Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.
Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.
Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.
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