A client has just had a cup of coffee, and the nurse needs to ...

[CBme]

A client has just had a cup of coffee, and the nurse needs to measure the body temperature. The nurse should:
 
  A. Take a rectal temperature
  B. Take an axillary temperature
  C. Use a tympanic membrane sensor
  D. Postpone the measurement for 5 minutes

Question 2

While assessing the patient's IV infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first?
 
  a. Discontinue the IV.
  b. Increase the rate of infusion.
  c. Observe for fluid overload.
  d. Check the position of the IV fluid and extremity.

[joshraies]

Answer to Question 1

C
A, B, C, D. Tympanic membrane sensor is unaffected by oral intake of food or fluids or smoking.

Answer to Question 2

D
Check the patient for positional changes that might affect infusion rate, height of the IV container, and tubing obstruction. Check the condition of the site. The most likely cause of a slow-running IV is positioning. An infiltrated or clotted IV line probably will not be running at all. Discontinue the IV if it is determined that it is infiltrated or clotted off. Position will affect flow even if rate is increased. Fluid overload is not associated with slowing of the infusion rate. Often it occurs when an IV is running too quickly.

[CBme]

TYSM

[amandalm]

Wow, this really help