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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blood pressure is 142/88 mm Hg:
While elevated blood pressure may have implications for cardiovascular health, it is not directly related to oxygen saturation levels measured by a pulse oximeter.
B. Radial pulse volume is 3+:
A strong radial pulse volume suggests adequate peripheral perfusion, which would not typically contribute to a low oxygen saturation reading.
C. 2+ edema of fingers and hands:
Edema of the fingers and hands can impair the transmission of light through tissues, which may interfere with the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edematous tissues may absorb light and lead to falsely low readings.
D. Capillary refill time is 2 seconds:
Normal capillary refill time indicates adequate peripheral circulation, which would not typically contribute to a low oxygen saturation reading.
Correct Answer is A
Explanation
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 isperforming 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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