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 A
Explanation
A. Provide a back rub at bedtime:
This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.
B. Leave the door to the client's room open slightly:
Leaving the door open may not prevent wandering and could potentially lead to safety issues.
C. Apply wrist restraints to prevent wandering:
Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.
D. Administer a PRN sedative prescription:
Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.
Correct Answer is B
Explanation
A. Observe the client's body language:
This strategy involves paying attention to the client's non-verbal cues, such as facial expressions, posture, and gestures, to gauge their level of understanding and engagement. While body language can provide valuable insights into the client's receptiveness to the information being presented, it may not always accurately reflect their comprehension or ability to recall important details. Therefore, while observing body language is beneficial, it should be supplemented with other strategies for a more comprehensive assessment of learning.
B. Ask the client for learning feedback:
This strategy involves actively soliciting feedback from the client to assess their understanding of the material presented. By asking questions such as, "Can you repeat back to me how you will take this medication?" or "Do you have any concerns or questions about the information I've provided?" the nurse can directly gauge the client's comprehension and address any areas of confusion or misunderstanding. Asking for learning feedback encourages active participation from the client and provides an opportunity for real-time clarification, making it a highly effective strategy for confirming learning.
C. Provide client-focused information:
This strategy involves tailoring the educational content to meet the specific needs, preferences, and learning styles of the client. By presenting information in a manner that resonates with the client's individual characteristics and circumstances, such as using plain language, visual aids, or culturally sensitive materials, the nurse can enhance the client's understanding and retention of the material. Providing client-focused information fosters a more personalized and relevant learning experience, which can contribute to better outcomes and adherence to treatment recommendations.
D. Reinforce key points with the client:
This strategy involves reviewing and emphasizing important information multiple times throughout the teaching session to reinforce learning and retention. Repetition helps solidify key concepts in the client's memory and increases the likelihood of successful recall and application of the information. By revisiting key points, summarizing key concepts, and providing opportunities for practice or self-assessment, the nurse can help reinforce the client's understanding and confidence in managing their medication regimen. Reinforcing key points with the client ensures that critical information is consistently emphasized and internalized, which is essential for promoting safe and effective medication use.
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