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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Correct Answer is D

Explanation

D. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.

A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.

B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.

C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.

A. was negligent, resulting in harm to the client. B. was acting on the principle of nonmaleficence. C. committed a misdemeanor. D. was unethical in her practice.

Correct Answer is A

Explanation

A. Negligence in nursing refers to the failure to provide care that meets established standards, resulting in harm to the patient. In this case, if the nurse failed to monitor vital signs as per hospital policies and this failure led to complications for the post-operative client, it could constitute negligence. Negligence involves breaching the duty of care owed to the patient, causing harm that could have been reasonably prevented.

B. Nonmaleficence is the principle of doing no harm. While it is an ethical principle guiding healthcare practice, it does not justify or excuse negligence. Negligence involves a failure to uphold the duty of care owed to the patient, resulting in harm due to substandard practice.

C. A misdemeanor typically refers to a lesser criminal offense. Negligence in healthcare generally does not rise to the level of a criminal offense like a misdemeanor unless there is gross negligence or willful misconduct. In most cases, negligence leading to harm is addressed through civil litigation rather than criminal charges.

D. While negligence can certainly be considered unethical behavior in the context of healthcare, negligence itself is a legal concept related to professional malpractice rather than solely an ethical breach. Ethical violations may involve different aspects of professional conduct not directly related to negligence, such as breaches of confidentiality or conflicts of interest.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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