Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?
A. The AP inserts the probe with a straightforward motion.
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
B. The AP positions the client facing her.
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
C. The AP pulls the pinna up and back
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
D. The AP points the probe posteriorly.
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice C. The AP pulls the pinna up and back.
Choice A rationale:
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
Choice B rationale:
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
Choice C rationale:
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
Choice D rationale:
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.
Similar Questions
A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?
A. I should practice pursed-lip breathing exercises.
Pursed-lip breathing exercises help to reduce dyspnea and improve oxygenation in clients who have COPD.
B. I will consume low-protein, low-calorie foods.
C. I will increase my fluid intake to 1,700 milliliters per day.
D. I should do aerobic exercises once per day.
Full Explanation
The correct answer is A. Pursed-lip breathing exercises help to reduce dyspnea and improve oxygenation in clients who have COPD.
A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching?
A. I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water.
B. I will place used sharp items in an empty cereal box for disposal.
C. I will put soiled dressings in a tied plastic bag before placing them in the trash.
Putting soiled dressings in a tied plastic bag before placing them in the trash reduces the risk of exposure to blood-borne pathogens for anyone who handles the trash.
D. I will use animal-skin condoms when having sex.
Full Explanation
The correct answer is C. Putting soiled dressings in a tied plastic bag before placing them in the trash reduces the risk of exposure to blood-borne pathogens for anyone who handles the trash.
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
A. Pressured speech
B. Catatonia
C. Memory loss that disrupts ADLS
Memory loss that disrupts activities of daily living (ADLs) is a common manifestation of dementia, which is a progressive decline in cognitive function. Pressured speech, catatonia, and illusions are more likely to be seen in clients who have psychotic disorders, such as schizophrenia or bipolar disorder.
D. Illusions
Full Explanation
The correct answer is C. Memory loss that disrupts activities of daily living (ADLs) is a common manifestation of dementia, which is a progressive decline in cognitive function. Pressured speech, catatonia, and illusions are more likely to be seen in clients who have psychotic disorders, such as schizophrenia or bipolar disorder.