A child has cancer, is unresponsive, and is doing poorly. Which action by the nursing student causes the faculty to intervene?
A.
Allows the parents to hold the child
B.
Places the child on NPO status
C.
Takes the child's rectal temperature
D.
Turns the child even if she moans
ANS: C
The nurse avoids the rectal route for anything: temperatures, suppositories, and enemas are not allowed, as the rectal mucosa is fragile and prone to injury, which can lead to infection. The other actions are appropriate.
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