The nurse takes a client's temperature and gets an unexpected result. Which site would provide the most accurate temperature reading?

Axillary

Skin

Oral

Rectal

Answer and Explanation

The Correct Answer is D

D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.

A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.

B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.

C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.

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Free Nursing Study Resources

Correct Answer is ["1700"]

Explanation

To calculate the time when a new IV bag will be needed, we can divide the total volume left in the bag by the infusion rate.

With 500 ml remaining and an infusion rate of 100 ml per hour, it will take 5 hours for the current bag to be depleted.

Since the report was given at 1200 (which is noon in military time), adding 5 hours brings us to 1700, or 5:00 PM.

Therefore, the nurse should expect to hang a new IV bag at 1700 hours in military time.

A. Measure vital signs. B. Lower the head of the bed. C. Verify tube patency. D. Assist the client to a prone position.

Correct Answer is C

Explanation

C. Before administering a feeding through a gastrostomy tube, it is essential to verify that the tube is patent (open and unobstructed). Tube patency ensures that the feeding formula or medication can flow freely into the stomach or intestines without encountering any blockages or resistance. The nurse should flush the tube with water to check for patency and ensure proper functioning before initiating the feeding.

A. Vital signs are typically assessed for overall health monitoring and to detect any immediate changes in the client's condition. However, they are not specifically required before every feeding via gastrostomy tube unless there are specific concerns about the client's stability.

B. This option is not typically necessary before administering a feeding through a gastrostomy tube. In fact, elevating the head of the bed to at least 30 to 45 degrees is often recommended during and after feeding to minimize the risk of aspiration. This position helps to promote digestion and reduce the likelihood of reflux or regurgitation of the feeding.

D. Assisting the client to a prone (face-down) position is unnecessary and potentially unsafe before administering a feeding through a gastrostomy tube. The recommended position for feeding via gastrostomy tube is typically semi-Fowler's position (elevated head of the bed), which helps prevent aspiration and facilitates digestion.

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The nurse takes a client's temperature and gets an unexpected result. Which site would provide the most accurate temperature reading?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving IV fluids at 100 ml per hour. The nurse is told in report at 1200 that there are 500 ml left in the bag. At what time should the nurse expect to hang a new bag? Report the time in military time.

Correct Answer is ["1700"]

Explanation

The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding?

Correct Answer is C

Explanation

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