The nurse observes the unlicensed assistive personnel (UAP) ...

[tfester]

The nurse observes the unlicensed assistive personnel (UAP) obtaining vital signs. Which would indicate a safe temperature measurement procedure?
 
  1. Taking an oral temperature on a 2-year-old child
  2. Taking a rectal temperature on a client who had a hemorrhoidectomy earlier this morning
  3. Taking an axillary temperature on a confused client who was combative earlier in the day
  4. Taking a tympanic temperature on a client with a large amount of cerumen in the ear

Question 2

The nurse is preparing to assess vital signs for clients currently assigned. For which client would measuring temperature via the rectal route be contraindicated?
 
  1. A comatose client with an oral endotracheal tube in place
  2. An adolescent client who has had recent maxillofacial surgery
  3. A toddler with previous temperature reading of 104.2 F axillary
  4. A client with a fever who is in a chronic vegetative state

[juwms]

Answer to Question 1

Correct Answer: 3

Taking the confused client's temperature axillary would be a safe and effective means of temperature measurement. Oral temperatures are generally contraindicated in a 2-year-old client due to the child's inability to cooperate. Rectal temperature should not be measured on a client who has had rectal surgery. The presence of a large amount of cerumen in the ear will result in an inaccurate tympanic measurement.

Answer to Question 2

Correct Answer: 2
The adolescent client is in a developmental stage where exposing the buttocks would be very embarrassing, so it would be best to take this client's temperature via the axillary or tympanic route. The comatose client or the client in a chronic vegetative state would not be embarrassed by a rectal temperature measurement, and it could be safely and accurately performed. The toddler with the extremely high temperature needs the most accurate temperature measurement, and would be an ideal candidate for measuring temperature via the rectal route.