The nurse observes the unlicensed assistive personnel (UAP) obtaining vital signs. Which would indicate a safe temperature measurement procedure?
1. Taking an oral temperature on a 2-year-old child
2. Taking a rectal temperature on a client who had a hemorrhoidectomy earlier this morning
3. Taking an axillary temperature on a confused client who was combative earlier in the day
4. Taking a tympanic temperature on a client with a large amount of cerumen in the ear
Correct Answer: 3
Taking the confused client's temperature axillary would be a safe and effective means of temperature measurement. Oral temperatures are generally contraindicated in a 2-year-old client due to the child's inability to cooperate. Rectal temperature should not be measured on a client who has had rectal surgery. The presence of a large amount of cerumen in the ear will result in an inaccurate tympanic measurement.
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