When planning to assess a client's temperature, the nurse ...

[Arii_bell]

When planning to assess a client's temperature, the nurse realizes that the safest, least invasive method of temperature measurement is:
 
  1. Rectal
  2. Oral
  3. Axillary
  4. Tympanic membrane

Question 2

The nurse positively evaluates the triage nurse's effectiveness when which of the following occurs?
 
  1. A client in severe pain is admitted before a client with asthma.
  2. A client with possible epiglottitis is admitted before a client with chest pain.
  3. A client with pulmonary edema is admitted before a client with neck trauma.
  4. A client with an earache is admitted before a client with a facial burn.

[duy1981999]

Answer to Question 1

3
Rationale: While rectal temperature measurement is the most reliable, it is the most invasive, and can cause injury to rectum

Answer to Question 2

2
Rationale: Following the ABCD method of triage, the client with a threat to airway (epiglottitis) should be admitted before a client with a threat to circulation (chest pain). A client with asthma should be admitted before the client in severe pain, because of the risk to airway and breathing. The client with neck trauma should be admitted before the client with pulmonary edema because neck trauma could block the airway. A client with a facial burn faces a threat to the intact airway, and should be seen before a client with an earache.