Prior to assessing the adult client's temperature rectally, which action by the nurse is the most appropriate?
1. Lubricate the tip of the thermometer.
2. Obtain a health care provider's order.
3. Position the client in the Trendelenburg position.
4. Position the client in the Fowler's position.
Correct Answer: 1
Prior to inserting the thermometer, the nurse should apply a water-soluble lubricant to the tip of the thermometer to prevent tissue damage. A health care provider's order is not required. Both the Trendelenburg and Fowler's positions would make obtaining a rectal temperature difficult; a side-lying position would be preferable.
You might also like to view...
Afterload refers to
A) cardiac workload. B) the amount of stretch placed on cardiac muscle fibers just before systole. C) the force against which the ventricle must eject blood during systole. D) the volume of blood in the ventricle at the end of diastole
An older patient develops rapid, shallow respirations, with retraction of the respiratory muscles. What will the nurse do first to improve this patient's ineffective breathing pattern?
A) Administer oxygen B) Prevent a respiratory infection C) Keep the nasal passages patent D) Raise the bed at least 30°
Which of the following would best identify foods to which a child is allergic?
A) A Elimination diet B) Hyposensitivity testing C) Complete dietary protein restriction D) Corticosteroid challenge testing
________ is a carbonic anhydrase inhibitor that continues to produce diuresis even in the presence of alkalosis.
A. Isosorbide B. Mannitol C. Acetazolamide D. Chlorothiazide