The licensed nurse is getting a report from an unlicensed assistive person in relation to the morning vital signs. Which statement would indicate that the rectal temperature needs to be taken via a different route?
A) "The client was on oxygen when I took the reading."
B) "I was unable to read the temperature because there was a small amount of stool on the thermometer."
C) "Because the client was confused, I took the temperature rectally."
D) "The client has had diarrhea three times this morning."
D
Feedback:
Rectal temperature measurement is contraindicated in conditions such as diarrhea and rectal disease, and following rectal surgery. Rectal temperature can be taken when caring for unconscious or confused clients, infants and young children, and after mouth surgery or for the client receiving oxygen, unless specifically contraindicated or if tympanic thermometers are available. When taking the rectal temperature, a small amount of stool will not affect the temperature reading.
You might also like to view...
The nurse has scheduled a vacation to attend a resort with the family over the children?s spring break. There is a flu epidemic and over 60% of the staff is unavailable to work
The nurse manager cancels all scheduled vacation and requires all staff to work the week of spring break. Using the managerial grid as a model, what type of management decision was made? 1. Country club 1,9 2. Team 9,9 3. Impoverished 1,1 4. Authority compliance 9,1
A nurse wanted a screening test that was very sensitive in determining who might have a particular illness. What might be a problem with using such a sensitive test? (Select all that apply.)
a. Many persons have true negative test results. b. Persons who test negative are able to celebrate their healthy state. c. Persons who do not have the illness are told that they might, which leads to anxiety, as well as time and cost of follow-up diagnostic tests. d. Such a test may have lower specificity, so some persons with the disease are told they are disease free and hence do not receive care. e. There is no problem; it is best to use the most sensitive screening test available. f. Persons who have the disease are notified and receive treatment.
The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Note: Credit will be given only for all correct choices and no incorrect choices. Select all that apply
1. Maternal exhaustion 2. Cervical edema 3. Tearing and bruising of the cervix 4. Enhanced perineal thinning 5. Having to perform an episiotomy
A school nurse at the local public high school has begun a program with his students that addresses safe sex and nonsmoking. This school nurse is classified as a(an)
A) Home health provider B) Moral force for the public C) Community care affiliate D) Tertiary prevention specialist