Answer to Question 1
Correct Answer: 2
Rationale 1: The 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 because this site is much farther away from the heart.
Rationale 4: The rectal site 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: 1
Rationale 1: If the equipment is not working properly, no accuracy will be obtained in the readings.
Rationale 2: The type of equipment or method that is chosen will dictate client position, not the position of the health care provider.
Rationale 3: If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the client's skin must be dry for the thermometer to adhere to the skin.
Rationale 4: The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes.
Heart Flow
B, The nurse teaches the postoperative client to use an incentive spirometer to expand the lungs.
Nursing history for rectal and anal assessment
Social History Questions
Amyloid plaques (stained blue) in the brain of a deceased patient who had Alzheimer’s disease.
The client is positioned for the examination