The nurse is preparing to assess vital signs for clients currently assigned. For which client would measuring temperature via the rectal route be contraindicated?
1. A comatose client with an oral endotracheal tube in place
2. An adolescent client who has had recent maxillofacial surgery
3. A toddler with previous temperature reading of 104.2 °F axillary
4. A client with a fever who is in a chronic vegetative state
Correct Answer: 2
The adolescent client is in a developmental stage where exposing the buttocks would be very embarrassing, so it would be best to take this client's temperature via the axillary or tympanic route. The comatose client or the client in a chronic vegetative state would not be embarrassed by a rectal temperature measurement, and it could be safely and accurately performed. The toddler with the extremely high temperature needs the most accurate temperature measurement, and would be an ideal candidate for measuring temperature via the rectal route.
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