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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.
Correct Answer is B
Explanation
A. Dysrhythmia. Dysrhythmia refers to an irregular heart rhythm, not necessarily a fast heart rate. Tachycardia can be regular or irregular.
B. Tachycardia. Tachycardia is defined as a heart rate above 100 beats per minute in adults. A pulse rate of 110 to 140 bpm falls within this range.
C. Bradycardia. Bradycardia refers to a slow heart rate (below 60 bpm), which is the opposite of tachycardia.
D. Pyrexia. Pyrexia refers to fever (elevated body temperature), not an increased heart rate.
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