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. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.
B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.
C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.
D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.
Correct Answer is D
Explanation
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B. Expressing hope to reduce the need for pain pills indicates the client understands the potential benefit of TENS in managing pain.
C. Wishing to avoid attaching electrodes indicates a common apprehension about the treatment but does not necessarily signify a misunderstanding of the TENS process.
D. The statement about having to be in the hospital suggests a misunderstanding since TENS is often used as an outpatient therapy and does not typically require hospitalization. This indicates the client needs further education about the treatment setting and process.