NCLEX- PN Ch. 10 Flashcards
The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personal (UAP). Which method, if noted by the UAP as being an appropriate method indicates the need for further teaching?
A. Taking a rectal temperature for a client who has undergone nasal surgery.
B. Taking an oral temperature for a client who cough and nasal congestion.
C. Taking an axillary temperature for a client who has just consumed hot coffee.
D. Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic.
B. Taking an oral temperature for a client who cough and nasal congestion.
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client’s room and finds the client drowsy and records the following vital signs: temperature 97.2F (36.2 C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and Spo2 of 93% on 3 L of oxygen via nasal cannula. What action would the nurse take first?
A. Document the findings.
B. Attempt to arouse the client.
C. Contact the primary health care provider (PHCP).
D. Check the mediation administration history on a the PCA pump.
B. Attempt to arouse the client.
