The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client 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?
Use positive reinforcement to affirm that the procedure is being performed correctly.
Remind the UAP to lubricate the thermometer before gently inserting in the ear.
Demonstrate the correct technique for pulling the client's auricle down and back.
Advise the UAP to hold the thermometer securely in place for a full three minutes.
The Correct Answer is A
A. Use positive reinforcement to affirm that the procedure is being performed correctly:
Use positive reinforcement to affirm that the procedure is being performed correctly: This is correct. Positive reinforcement is important for encouraging and motivating staff, it should be used appropriately. In this case, the UAP is performing the procedure correctly
B. Remind the UAP to lubricate the thermometer before gently inserting it in the ear:
Lubrication is not typically necessary for tympanic thermometers. However, the primary issue in this scenario is the incorrect technique for positioning the client's auricle, so reminding about lubrication is not the most relevant intervention.
C. Demonstrate the correct technique for pulling the client's auricle down and back:
This is incorrect action to take. The UAP is using the correct technique.
D. Advise the UAP to hold the thermometer securely in place for a full three minutes:
Tympanic thermometers typically provide rapid temperature readings within a few seconds, so holding the thermometer in place for three minutes is unnecessary and may cause discomfort to the client. Additionally, the primary issue in this scenario is the incorrect technique for positioning the client's auricle, not the duration of thermometer insertion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Criminal assault and battery:
Criminal assault and battery involve intentionally causing harm to another person without their consent. In this scenario, the nurse's actions were aimed at providing aid and ensuring the victim's safety. There is no indication of any intentional harm or violence toward the victim.
B. Negligent acts of omission:
Negligent acts of omission occur when a healthcare provider fails to act in a manner consistent with the standard of care, resulting in harm to another person. In this scenario, the nurse took certain actions to assist the victim, such as turning off the engine key and assessing the victim's condition. There is no indication of negligent omission as the nurse took appropriate actions given the circumstances.
C. Abandonment of the victim:
This applies if a healthcare professional leaves a patient in need of care without ensuring appropriate transfer of care. In this scenario, the nurse handed over the situation to EMS before leaving.
D. Good Samaritan immunity:
Good Samaritan laws protect individuals, including nurses, who voluntarily provide assistance in emergency situations from legal liability, as long as their actions are within the scope of their knowledge and training and are performed in good faith. The nurse stopped to help, provided care, and then reported to EMS personnel before leaving, which is consistent with the protection offered by Good Samaritan laws.
Correct Answer is B
Explanation
A. Regular exercise:
Regular exercise is important for overall cardiovascular health and can help reduce the risk of developing heart disease. However, smoking cessation is more crucial because smoking is a significant risk factor for heart disease and quitting smoking has immediate and long-term benefits for heart health.
B. Smoking cessation:
Smoking is a major risk factor for heart disease as it damages the blood vessels, increases blood pressure, reduces oxygen supply to the heart, and promotes the formation of blood clots. Encouraging smoking cessation is essential for reducing the risk of heart disease and improving overall health.
C. Low-fat diet:
Adopting a low-fat diet can help lower cholesterol levels and reduce the risk of heart disease, but it may not be as critical as smoking cessation for individuals with a family history of cardiac disease.
D. Stress reduction:
While stress reduction techniques such as relaxation exercises, meditation, and mindfulness can be beneficial for heart health, addressing smoking cessation is more urgent for individuals with a family history of cardiac disease, as smoking is a more significant risk factor for heart disease.
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