Which of the following sites would be the most appropriate choice ...

[Diane]

Which of the following sites would be the most appropriate choice to use to measure a client's temperature who has a history of heart disease and has just eaten a bowl of vegetable soup?
 
  1. Axilla
  2. Oral
  3. Popliteal
  4. Rectal

Question 2

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds capillary refilling time.
 
  How would the nurse explain these findings?
  1. A change in the client's health status has occurred.
  2. The client has thrown a blood clot in that extremity.
  3. The RN's watch has stopped working.
  4. Too much pressure was applied over the pulse site.

[nikmaaacs]

Answer to Question 1

Correct Answer: 2
Rationale 1: Axilla is the preferred site for newborns, not adults.
Rationale 2: Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used.
Rationale 3: The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading since this site is much farther away from the heart.
Rationale 4: Rectal would be contraindicated in this client given the history of heart disease. With the diagnosis of heart disease, the nurse would need to assess for the presence of hemorrhoids.

Answer to Question 2

Correct Answer: 4
Rationale 1: The information provided gives no indication that any health change has occurred.
Rationale 2: The assessment data given (warm, pink, etc.) are not symptoms of a blood clot.
Rationale 3: There is no data given in regard to equipment malfunction like a watch.
Rationale 4: Too firm of pressure on a pulse site will obliterate that pulse since assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery, making contact with the cones in the foot.

[Diane]

TYSM

[bdobbins]

Gracias!