Review Temperature Measurement:

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Temperature Measurement:

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Total Questions : 5

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Question 1:

A nurse is assessing a client's body temperature. Which route provides the most accurate measurement of core body temperature?

A. Oral B. Axillary C. Temporal D. Rectal

Answer and Explanation

Choice A:

The oral route is commonly used and provides a convenient method for temperature measurement but may be influenced by oral intake and respiratory route, making it slightly less accurate.

Choice B:

The axillary route is less invasive and easier to use, but it tends to underestimate core body temperature.

Choice C:

The temporal route provides a quick measurement but may not be as accurate as the rectal route, especially in certain populations.

Choice D:

The rectal route provides the most accurate measurement of core body temperature as it reflects the temperature of blood perfusing the hypothalamus, which regulates body temperature.

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Question 2:

A nurse is assessing a client's body temperature and obtains a reading of 102°F (38.9°C). What action should the nurse take?

A. Administer antipyretic medication. B. Document the temperature and continue monitoring. C. Apply cool compresses to the client's forehead. D. Notify the healthcare provider immediately.

Answer and Explanation

Choice A:

Administering antipyretic medication may be appropriate based on the client's symptoms and healthcare provider's orders, but it is not the immediate action for a single temperature reading of 102°F.

Choice B:

Document the temperature and continue monitoring. Explanation: A temperature reading of 102°F (38.9°C) indicates a fever but does not require immediate intervention unless accompanied by other significant symptoms or in certain high-risk populations. The nurse should document the temperature and continue monitoring the client's condition.

Choice C:

Applying cool compresses can provide comfort to the client but does not address the underlying cause of the fever.

Choice D:

Notifying the healthcare provider immediately is not necessary based solely on a temperature reading of 102°F without other significant symptoms or concerns.

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Question 3:

A nurse is assessing a client's body temperature using a tympanic thermometer. How should the nurse position the thermometer for accurate measurement?

A. Place the thermometer in the client's mouth. B. Insert the thermometer into the client's rectum. C. Aim the thermometer at the client's forehead. D. Position the thermometer in the client's ear canal.

Answer and Explanation

Choice A:

Placing the thermometer in the mouth is appropriate for oral temperature measurement but not for tympanic thermometers.

Choice B:

Aiming the thermometer at the forehead is appropriate for temporal artery thermometers but not for tympanic thermometers.

Choice C:

Aiming the thermometer at the forehead is appropriate for temporal artery thermometers but not for tympanic thermometers.

Choice D:

Position the thermometer in the client's ear canal.

Explanation: Tympanic thermometers are used by positioning the thermometer in the client's ear canal to obtain an accurate measurement of body temperature.

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Question 4:

A nurse is assessing a client's body temperature using an electronic thermometer. How long should the nurse leave the thermometer in place to obtain an accurate reading?

A. 5 seconds B. 10 seconds C. 20 seconds D. 1 minute

Answer and Explanation

Choice A:

5 seconds is typically not sufficient to obtain an accurate reading with an electronic thermometer.

Choice B:

10 seconds may be sufficient for certain electronic thermometers, but 20 seconds is generally recommended for accuracy.

Choice C:

To obtain an accurate reading using an electronic thermometer, the nurse should leave the thermometer in place for approximately 20 seconds or as recommended by the manufacturer's instructions.

Choice D:

1 minute is longer than necessary for most electronic thermometers and may not provide any additional benefit in terms of accuracy.

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Question 5:

A nurse is assessing a client's body temperature and notices shivering and goosebumps. What action should the nurse take?

A. Cover the client with warm blankets. B. Administer an antipyretic medication. C. Apply cool compresses to the client's forehead. D. Notify the healthcare provider immediately.

Answer and Explanation

Choice A:

Shivering and goosebumps are signs of the body's attempt to increase body temperature. The nurse should cover the client with warm blankets to prevent heat loss and promote comfort.

Choice B:

Administering an antipyretic medication is not appropriate in this scenario as shivering and goosebumps indicate the body's attempt to increase body temperature, not fever.

Choice C:

Applying cool compresses is not appropriate when the client is experiencing shivering and goosebumps, as the goal is to prevent heat loss

Choice D:

Notifying the healthcare provider immediately is not necessary based on shivering and goosebumps alone, as they are normal physiological responses to cold or low body temperature.

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Temperature Measurement:

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