The nurse is preparing to obtain a rectal temperature. Nursing care is correct if the nurse inserts the thermometer how far into the rectum of an adult?
a. 1.3 cm (1/2 inch)
b. 3.5 cm (1 1/2 inches)
c. 5.1 cm (2 inches)
d. 6.4 cm (1 1/2 inches)
B
The nurse inserts the thermometer 2.5 to 3.5 cm (1 to 1 1/2 inches) to obtain a rectal temperature on an adult. The sensor tip will be deep enough into the rectum to eliminate environmental ef-fects but not too deep to risk penetration or trauma to intestinal tissue. 1.3 cm (1/2 inch) is not far enough for an accurate reading. 5.1 and 6.4 cm (2 and 2 1/2 inches) are too far to insert the thermometer into an adult.
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