A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?
Proceed to measure the oral temperature.
Document that the nurse was unable to measure the client's temperature.
Provide the client a sip of warm water, wait 5 min, and measure the temperature.
Wait 30 min and return to measure the oral temperature.
The Correct Answer is D
A. Proceeding to measure the oral temperature immediately after the client has consumed ice chips can lead to an inaccurate reading due to the cooling effect of the ice.
B. Documenting that the nurse was unable to measure the client's temperature is unnecessary; it is possible to obtain an accurate measurement after a suitable waiting period.
C. Providing a sip of warm water will not resolve the issue of the ice chips affecting the temperature reading, as the nurse should still wait a longer period for accuracy.
D. Waiting 30 minutes after the client has consumed ice chips is the best practice, as it allows sufficient time for the oral cavity to return to a baseline temperature for an accurate measurement.
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Correct Answer is D
Explanation
A. Using each cleansing wipe twice is not appropriate, as this may cause cross-contamination; each wipe should be used once.
B. Cleaning the inside of the container is unnecessary and may introduce contaminants; only the outside should be kept clean.
C. The correct method involves urinating a little, stopping to allow for midstream collection, and then continuing to urinate; saying "then stop" may confuse the procedure.
D. Using the cleansing wipe from front to back is the correct technique for women to prevent urinary tract infections (UTIs) and ensure proper hygiene during sample collection.
Correct Answer is D
Explanation
A. Filling out an occurrence form is necessary for documentation and accountability but is not the immediate priority after a medication error.
B. Administering the medication to the correct client should be done, but first, the nurse must ensure the safety and well-being of the client who received the wrong medication.
C. Notifying the client's provider is essential, but the nurse should first assess the client's condition to determine if any immediate actions are necessary.
D. Checking the client's vital signs is the first action the nurse should take to assess the client's current condition and any potential adverse effects from receiving the incorrect medication.