A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An ap-propriate action would be to:
1. Take the rectal temperature
2. Take the oral temperature as planned
3. Have the child rinse out the mouth with warm water
4. Wait 20 minutes before assessing the oral temperature
ANS: 4
The nurse should wait 20 to 30 minutes before measuring the oral temperature. The nurse should wait, rather than measuring the child's temperature rectally, as this is not an emergency situation. Taking the oral temperature at this time would result in an inaccurate reading. Rinsing the mouth with warm water may also provide an inaccurate reading of the child's actual body temperature. The nurse should wait 20 minutes and measure the child's oral temperature.
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