When inserting a rectal thermometer, the nurse encounters resistance. The nurse should:
a. apply mild pressure to advance.
b. ask the patient to take deep breaths.
c. remove the thermometer immediately.
d. remove the thermometer and reinsert it gently.
C
If resistance is felt during insertion, withdraw the thermometer immediately. Never force the thermometer. This prevents trauma to the mucosa. With the nondominant hand, separate the patient's buttocks to expose the anus. Ask the patient to breathe slowly and relax. This fully exposes the anus for thermometer insertion and relaxes the anal sphincter for easier thermometer insertion.
You might also like to view...
Which option best reflects a driving force in the process of change?
1. A financial deficit of millions of dollars 2. A staff composed of long-term employees 3. An ineffective nurse manager 4. An administration composed of long-term employees
A client is admitted to the unit with chronic obstructive pulmonary disease. Blood gas analysis indicates respiratory acidosis. Based on this data, the nurse plans care based on which priority diagnosis?
A) Impaired Gas Exchange B) Ineffective Airway Clearance C) Impaired Mobility D) Anxiety
The clinic nurse will immediately alert the health care provider when which category X drugs are identified on a recently diagnosed pregnant client?
1. Tetracycline 2. ACE inhibitor antihypertensive medication 3. Methotrexate 4. Isotretinoin (Accutane) 5. Oral contraceptives
The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching?
a. "I can't wait to get the baby home to play with the brothers and sisters." b. "I will ask my mom to come after the first week, when the baby is more alert." c. "I can get the baby on a sleeping schedule the first week while my mom is here." d. "I won't be able to nap during the day because the baby will be awake."