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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B Watching exciting or stimulating movies, especially horror movies, before bedtime can hinder sleep onset. Such activities can increase arousal and make it more difficult to relax and fall asleep. This statement suggests a lack of understanding of good sleep hygiene practices. Further teaching is needed to discourage stimulating activities before bedtime.
A. Consistency in sleep schedule helps regulate the body's internal clock (circadian rhythm) and can promote better sleep quality. There is no need for further teaching regarding this statement.
C. This statement reflects good sleep hygiene advice. Getting up and engaging in a quiet, boring activity if unable to fall asleep after about 30 minutes can prevent frustration and anxiety associated with lying awake in bed. This practice helps condition the mind to associate the bed with sleep rather than wakefulness. There is no need for further teaching regarding this statement.
D. This statement also reflects good sleep hygiene practices. Going to bed when feeling naturally tired can enhance the ability to fall asleep quickly. It aligns with the concept of associating the bed with sleepiness and promotes sleep onset. There is no need for further teaching regarding this statement.
Correct Answer is C
Explanation
C. A comprehensive approach ensures that all aspects of patient care, safety, and organizational processes are thoroughly reviewed and addressed according to TJC standards. This includes comprehensive assessments of patient needs, care plans, and quality improvement initiatives.
A. This term typically refers to the process of capturing images or videos at intervals over time. In the context of healthcare and TJC requirements, "time-lapsed" is not a standard term used by TJC.
B An emergency situation refers to a sudden and often critical medical situation requiring immediate attention and intervention. While TJC does have standards related to emergency preparedness and response in healthcare facilities, "emergency" is not specifically a type of TJC requirement in the context provided.
D. A focused approach refers to concentrating on specific areas or issues within healthcare organizations to address particular concerns or improvements. However, this is not specific about TJC.
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