While inserting a rectal thermometer, the nurse encounters resistance. What action should the nurse take?
a. Remove the thermometer immediately.
b. Ask the patient to take a few deep breaths.
c. Apply mild pressure to advance the ther-mometer.
d. Remove the thermometer and reinsert gently.
A
If resistance is felt, the nurse should remove the thermometer probe. Applying pressure to ad-vance the thermometer is contraindicated to prevent complications such as harm to the mucosa. If there is an obstruction or a large amount of stool, having the patient take a few deep breaths is useless. The obstruction or impaction will have to be dealt with first. If the nurse removes and then reinserts the thermometer, the stimulation reactivates the sphincter reflex. The resistance will more than likely still be present.
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