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 D
Explanation
A. Withdraw the medication into a syringe and label it with the client's name:
This is not necessary for the remainder of the medication. The medication should not be withdrawn into a syringe for future use or left labeled, as it could lead to errors or contamination.
B. Throw the vial into the trash in the presence of another nurse:
Discarding the vial into the trash is not appropriate, as it does not ensure proper documentation, accountability, or safe storage of the remaining medication. Additionally, the presence of another nurse does not address these concerns.
C. Place the vial with the remainder of the medication into a locked drawer:
While storing the vial in a locked drawer may prevent unauthorized access, it does not address the need for proper documentation and labeling of the remaining medication. Additionally, the vial should not be stored with the medication still in it after withdrawal.
D. Ask another nurse to witness the medication being discarded:
This is the appropriate action. Many facilities require that the disposal of unused or remaining medications, especially controlled substances, be witnessed by another nurse to ensure accountability and compliance with regulations.
Correct Answer is C
Explanation
A. Elevate the head of the bed to a 45-degree angle:
Elevating the head of the bed can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. While this intervention is important, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.
B. Lift and lock the side rails in place:
Ensuring the safety of the client by lifting and locking the side rails is important, but it does not directly address the client's OSA or the potential respiratory depression associated with opioid analgesic administration.
C. Apply the client's positive airway pressure device:
This is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.
D. Remove dentures or other oral appliance:
While removing dentures or other oral appliances may be necessary for client comfort and safety, it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.
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