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 C
Explanation
A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.
B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.
C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.
D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.
Correct Answer is D
Explanation
A. While completing an incident report is important for documentation and quality improvement, it is not the immediate priority in the event of a medication error.
B. Notifying the nurse manager is a necessary step for reporting the error, but it should occur after ensuring the client's safety.
C. Calling the client's provider is essential to discuss the medication error and possible interventions, but the client's health and safety must be assessed first.
D. Assessing the client is the priority action to ensure the client’s safety and to identify any adverse effects resulting from the wrong medication. The nurse needs to determine the client's vital signs, level of consciousness, and any immediate symptoms related to the medication administered.