The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use?
1. Axilla
2. Oral
3. Popliteal
4. Rectal
Correct Answer: 2
Rationale 1: The axilla is the preferred site for newborns, not adults.
Rationale 2: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used.
Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading because this site is much farther away from the heart.
Rationale 4: The rectal site would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids.
You might also like to view...
A patient with benign prostatic hypertrophy (BPH) has been prescribed terazosin (Hytrin). How do alpha-adrenergic blockers, such as terazosin, assist in treating the symptoms of BPH?
A) They increase gastric motility. B) They increase skeletal muscle contraction. C) They inhibit contraction of the urinary bladder. D) They decrease blood pressure.
A client with colon cancer has surgery with a colostomy. Which assessments indicate to the nurse that the client is developing postoperative complications? (Select all that apply.)
a. Urine output > 30 mL/hr b. Dusky appearance of the stoma c. Stoma protrusion from the skin d. Small amount of blood-tinged liquid stool in colostomy bag e. Edema of the stoma during the first 24 hours post-operation f. Sharp abdominal pain
A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply
A) Vitamins B) Proteins C) Fats D) Minerals E) Carbohydrates
Some of the nurses in the organization are preparing to unionize due to longstanding issues related to mandatory overtime policies enforced by the health care organization
Which of the following statements by a nurse supervisor is an example of an unfair labor practice? 1. "It's up to you as nurses to decide for yourselves whether you want to join a union." 2. "The rights of those who refrain from joining the union are as important as the rights of those of you who do join." 3. "It doesn't matter to me how you decide to organize yourselves." 4. "I'm sorry that the time I've chosen for your mandatory staff meeting is at the same time as your union meeting."