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 A
Explanation
A. Cleaning and drying the area before applying the patch is essential to ensure proper adhesion and effectiveness of the medication. This statement indicates the client understands proper application procedures.
B. Using lotion on irritated skin before applying a new patch can interfere with the patch's ability to adhere and may affect medication absorption. Therefore, this statement indicates a lack of understanding.
C. Removing the old patch and applying a new one in the same location is generally not recommended because it can lead to skin irritation and decreased absorption. This indicates a misunderstanding of proper patch rotation.
D. While pressing the patch securely is important, it is not as critical as ensuring the skin is clean and dry before application. Thus, this statement alone does not indicate full understanding of the teaching.
Correct Answer is A
Explanation
A. Dehydration is a common finding in clients who have experienced diarrhea for several days, as they may have lost significant fluid and electrolytes.
B. A rigid abdomen is more characteristic of conditions such as perforation or severe peritonitis rather than diarrhea.
C. Decreased bowel sounds may occur in certain conditions, but diarrhea typically presents with increased bowel sounds due to hyperactivity.
D. Hypothermia is not a common finding associated with diarrhea; instead, clients may have a normal or elevated temperature due to potential underlying infections.