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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Keeping a pair of gloves in a uniform pocket:

While it may be convenient to carry gloves, this action alone does not necessarily indicate an understanding of appropriate gloving procedures. Simply having gloves readily available does not ensure that they are used correctly or in accordance with infection control protocols.

B. Using sterile gloves when handling body fluids:

This action indicates an understanding of the need for sterile gloves when handling potentially infectious body fluids. However, it's important to note that not all situations require sterile gloves, and the use of sterile gloves should be based on the specific clinical context and infection control guidelines.

C. Donning sterile gloves when caring for clients with HIV:

While wearing gloves when caring for clients with HIV is important for infection control, not all situations require sterile gloves. The use of sterile gloves should be based on the specific clinical context and infection control guidelines.

D. Putting on new gloves when entering a client's room:

This action demonstrates an understanding of the importance of donning clean gloves when entering a client's room to prevent the spread of infection. It indicates adherence to standard precautions and proper infection control practices, making it the most appropriate choice.

A. Administer PRN oral pain medication. B. Review the pain medications prescribed. C. Ask the client what is causing the grimacing. D. Monitor the client's nonverbal behavior.

Correct Answer is C

Explanation

A. Administer PRN oral pain medication:

Administering pain medication without further assessment may not be appropriate, as the client's pain needs must be fully evaluated before intervening with medication. Additionally, pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

B. Review the pain medications prescribed:

While it's important to review the client's pain medications, particularly if the client is exhibiting signs of uncontrolled pain, this intervention should be secondary to further assessment of the client's current pain status.

C. Ask the client what is causing the grimacing:

Asking the client directly about the cause of their grimacing can help clarify their discomfort and provide insight into whether their pain response is being underreported. This approach helps bridge the gap between nonverbal cues and verbal reports.

D. Monitor the client's nonverbal behavior:

While monitoring nonverbal behavior is important, it does not directly address the discrepancy between the client’s grimacing and their verbal denial of pain. This action should be complemented by further assessment to understand the cause of the nonverbal signs.

E. Establish a regular time for going to bed and getting up: This intervention is not relevant to the current situation, as the client is experiencing discomfort while moving.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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