While inserting a rectal thermometer, the nurse encounters resistance. The nurse should:

Ask the client to take deep breaths

Remove the thermometer and reinsert more forcefully

Apply mild pressure to advance

Remove the thermometer immediately

Answer and Explanation

The Correct Answer is D

A. Ask the client to take deep breaths. Deep breathing can help relax the anal sphincter, but if resistance is already encountered, forcing the thermometer further could cause injury.
B. Remove the thermometer and reinsert more forcefully. Forcing the thermometer can cause damage to the rectal mucosa, leading to pain, bleeding, or even perforation.
C. Apply mild pressure to advance. Any resistance suggests a possible obstruction, such as stool or anatomical issues. Applying pressure could cause harm, so the thermometer should not be advanced further.
D. Remove the thermometer immediately. If resistance is encountered, the safest action is to withdraw the thermometer to prevent injury. The nurse should reassess the situation and consider alternative temperature measurement methods.

Nursing Test Bank

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Correct Answer is ["1.5"]

Explanation

Calculation:

Volume to administer = Dose ordered/ Dose available

Given:

Ordered dose = 75 mg
Available concentration = 50 mg/mL

Volume = 75mg/ (50mg/mL)

= 1.5mL

Thus, the nurse will administer 1.5 mL.

A. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension. B. The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment. C. The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension D. The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made.

Correct Answer is A

Explanation

A. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension. Hypertension is diagnosed based on persistently elevated blood pressure readings across multiple visits, rather than a single elevated measurement.
B. The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment. While stress can temporarily elevate blood pressure, a diagnosis should be based on multiple readings rather than withholding information from the patient.
C. The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension. A cardiology consult is not required to diagnose hypertension; primary care providers can diagnose and manage hypertension independently.
D. The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made. A reading of 180/100 mmHg indicates hypertensive crisis, but hypertension is diagnosed when blood pressure is consistently ≥140/90 mmHg on multiple occasions.

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While inserting a rectal thermometer, the nurse encounters resistance. The nurse should:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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