Quiz: Assessing Body Temperature

Early morning

A person's core body temperature is lowest during which part of the day? Night Late afternoon Noon Early morning

Put the stethoscope at the apical site and watch its movement.

A nurse is having difficulty observing the rise and fall of a client's chest when assessing respirations. Which action would be most appropriate? Document the rate as unattainable at this time. Put the stethoscope at the apical site and watch its movement. Ask the client if he or she is having trouble breathing at this time. Have the client breathe deeply in and out of the mouth.

1 in (2.5 cm)

During measurement of a rectal temperature, the thermometer probe should be inserted about how many inches (centimeters) into the anus in an infant? 1 in (2.5 cm) 1.5 in (3.75 cm) 2 in (5 cm) 0.5 in (1.25 cm)

Assess the heart rate Assess the blood pressure Remove the thermometer probe

The nurse is taking a rectal temperature on a client. The client reports dizziness and then faints. What actions should the nurse take? Select all that apply. Notify the health care provider Assess the heart rate Keep the client warm Assess the blood pressure Remove the thermometer probe

Fluid draining from the ear

The nurse determines that it would be inappropriate to obtain a tympanic temperature for the client with which problem? An acute ear infection Fluid draining from the ear An intact eardrum Large amounts of cerumen in the ear

"I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."

The nurse has just measured an adult client's oral temperature and obtained a result of 102.4°F (39.1°C). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate? -"I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." -"Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." -"I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly." -"You will need to remain NPO until I notify your health care provider about your increased temperature."

Discard the probe cover

The nurse has taken a client's temperature using a tympanic thermometer. What should the nurse do next? Remove gloves Place the machine in the charger Discard the probe cover Turn off the machine

Assess the client's temperature about 30 minutes after the client has finished drinking the coffee.

The nurse is planning to take a client's temperature orally. The nurse enters the room and observes the client drinking a cup of coffee. Which action would be most appropriate? -Ask the client to stop drinking coffee so that the temperature can be assessed currently. -Assess the client's temperature about 30 minutes after the client has finished drinking the coffee. -Obtain a rectal thermometer and plan to assess the client's temperature rectally instead. -Have the client notify the nurse when the client has finished drinking so the nurse can take the temperature then.

Deep in the posterior sublingual pocket

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which areas of the client's mouth? Along either upper gum line adjacent to an incisor Superior to the tongue with the tip touching the hard palate In the inferior buccal space on either side of the tongue Deep in the posterior sublingual pocket

Assist the client to a side-lying position.

The nurse is preparing to assess a client's temperature rectally. The client is lying supine in bed. What should the nurse do first? Assist the client to a side-lying position. Put on nonsterile disposable gloves. Expose the client's buttocks. Adjust the bed to a comfortable working height.

Lightly compress the client's radial artery using the first, second, and third fingers.

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? Encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first fingers of both hands. Grasp the client's inner wrist with the nondominant thumb positioned over the radial artery. Lightly compress the client's radial artery using the first, second, and third fingers. Compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns.

Disposable probe cover Water-soluble lubricating gel An electronic thermometer with a rectal probe

The nurse is preparing to measure a client's rectal temperature. Which supplies and equipment should the nurse have available before beginning the procedure? Select all that apply. Sterile gloves Disposable probe cover Water-soluble lubricating gel An electronic thermometer with a rectal probe A bedpan

Ensure that the thermometer is on and ready.

The nurse is preparing to measure a client's tympanic temperature. After performing hand hygiene and identifying the client, what would the nurse do next? Slide the disposable cover onto the probe. Insert the probe into the client's ear. Push the trigger button to activate the thermometer. Ensure that the thermometer is on and ready.

1 in (2.5 cm)

The nurse is providing care for a 3-year-old toddler and needs to take the child's temperature rectally. How far should the nurse insert the probe into the rectum? 2 in (5.0 cm) 1.5 in (3.75 cm) 1 in (2.5 cm) 0.5 in (1.25 cm)

Rectal

The nurse is providing care to a client who has a low platelet and white blood cell count. When assessing the client's temperature, which method would method would be contraindicated? Oral Tympanic Axillary Rectal

1.5 in (3.75 cm)

The nurse prepares to obtain a rectal temperature on an adult client. To which distance should the nurse insert the thermometer? 0.5 in (1.25 cm) 1 in (2.5 cm) 2 in (5.0 cm) 1.5 in (3.75 cm)

Water soluble lubricant

The nurse prepares to obtain a rectal temperature on an adult client. What lubricant should the nurse prepare for the thermometer probe? Cool tap water Petroleum jelly Water soluble lubricant Normal saline

Document the temperature as taken.

The unlicensed assistive personnel (UAP) measures the client's axillary temperature shortly after the client has taken a shower. The temperature is lower than the client's previous baseline. What should the UAP do next? Have the nurse retake the temperature. Document the temperature as taken. Take the temperature orally. Retake the temperature.

In the center of the axilla

When measuring a client's axillary temperature, the nurse would position the thermometer at which location? In the center of the axilla In the crease of the shoulder Just inside the fold between the arm and chest Between the midpoint of the arm and ribs

Up and back.

When obtaining a tympanic temperature of an adult client, the nurse would pull the pinna in which direction? Up and back. Laterally, then down. Down and back. Down, then up.

Toward the jawline

When taking a tympanic temperature on a client, the nurse should place the thermometer into the client's ear at what angle? Resting in the outer ear canal Toward the jawline Upward toward the forehead Straight into the ear

It maintains the client's dignity. It keeps the client warm.

When taking an axillary temperature, the nurse exposes only the axilla area. What reasons does the nurse tell the client? Select all that apply. It makes it easier for the nurse. It maintains the client's dignity. It keeps the client warm. It allows for an accurate temperature reading. It doesn't require repositioning the client.

Ear infection Earwax Ear drainage

Which can lead to an inaccurate tympanic temperature reading? Select all that apply. Ear infection Earwax Scarred tympanic membrane Having slept with one ear against a pillow Ear drainage Having drunk a cold beverage