Where would the nurse measure temperature if the client was confused and disoriented following rectal surgery?
1. Rectally
2. Orally
3. Axillary
4. Either orally or tympanically
Correct Answer: 3
The best means of checking this client's temperature would be axillary. A rectal temperature would be contraindicated by rectal surgery. The client who is confused should not have an oral temperature taken for fear the client will bite down on the thermometer and injure himself. The tympanic route would be acceptable, but oral would be contraindicated.
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