A nurse assesses a neonate's temperature by using a temporal artery scanner. What intervention should the nurse implement if the neonate's temperature is 99.5 ° F?
a. Record the findings
b. Notify the physician
c. Check the axillary temperature
d. Check the tympanic temperature
ANS: A
The neonate's temperature normally ranges from 96 ° to 99.5 ° F (35.5 ° to 37.5 ° C). Temperature regulation is labile (unstable) during infancy because of immature physiological mechanisms. Axillary measurement is considered the least accurate method and is used less frequently since the advent of the tympanic membrane thermometer. Tympanic thermometer readings are suitable for patients of all ages, except infants.
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Which statement regarding construct validity of a measurement instrument is accurate?
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a. first informing him of what you are doing. b. counting the number of respirations in 15 seconds and multiplying by 2. c. counting the respirations while measuring his pulse. d. placing the stethoscope on his chest so he does not know you are counting respirations.
Before administering any medication, what is the nurse's priority action regarding patient safety?
a. Verifying orders with another nurse b. Documenting the medications given c. Counting medications in the medication cart drawers d. Checking the patient's identification using two identifiers