Nokea
The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?
- A. Advise the UAP to hold the thermometer securely in place for a full three minutes.
- B. Use positive reinforcement to affirm that the procedure is being performed correctly.
- C. Demonstrate the correct technique for pulling the client’s auricle down and back.
- D. Remind the UAP to lubricate the thermometer before gently inserting it in the ear.
Correct Answer: B
Rationale: Up-and-back is correct for adults.
You may also like to solve these questions
The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
- A. Encourage increased fluid intake and measure urinary output every 8 hours.
- B. Provide comfort measures such as topical warm application and tactile massage.
- C. Determine client’s objective measure of pain using a numerical pain scale.
- D. Assist the client to ambulate as much as possible during waking hours.
- E. Implement a 24-hour schedule of routine administration of prescribed analgesics.
Correct Answer: B,C,E
Rationale: Comfort, assessment, and analgesics manage pain.
The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?
- A. Determine the client’s activity tolerance.
- B. Teach the client to shorten the stride to prevent falls.
- C. Initiate a fall risk protocol for the client.
- D. Record the client’s ability to perform ADLs safely.
Correct Answer: D
Rationale: Documentation reflects functional status.
To assess the quality of the client’s abdominal pain, which approach should the nurse use?
- A. Provide a numeric pain scale.
- B. Ask the client to describe the pain.
- C. Observe body language and movement.
- D. Identify effective pain relief measures.
Correct Answer: B
Rationale: Descriptive assessment captures pain quality.
An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Send the UAP to be fitted for a particulate filter mask immediately.
- B. Instruct the UAP that a standard face mask is sufficient.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Advise the UAP to wear a standard face mask to obtain vital signs.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.
A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?
- A. Administer a PRN sedative prescription.
- B. Leave the door to the client’s room open slightly.
- C. Apply wrist restraints to prevent wandering.
- D. Provide a back rub at bedtime.
Correct Answer: B
Rationale: Back rub addresses agitation non-pharmacologically.