NSG 3100 Exam Preparation Questions and Assured Success Solutions Newly updates 2024/2025
Assessing orally: what is the patients’ level of consciousness? is the patient, awake, alert, oriented - correct answer Intervention: select an alternative route to measure temp if unconscious
Assessin...
Assessing orally: what is the patients’ level of consciousness? is
the patient, awake, alert, oriented - correct answer
Intervention: select an alternative route to measure temp if
unconscious
Assessing orally: are there any mouth lesions or sores? - correct
answer intervention: select an alternative route to measures if
lesions or sores
Assessing temporal: does the patient exhibit extreme
perspiration - correct answer intervention: use a different
method. extreme perspiration interferes with the accuracy of the
temp reading
Assessing temporal: is the patient lying on their side? - correct
answer intervention: use the side of the patient face that is not
on the pillow. the side of the face that is on the pillow has an
artificially high temp
Assessing temporal: does the nurse suspect an inaccurate or
unreliable result - correct answer intervention: wait 30 seconds
before repeating the temp. it takes at least 30 seconds for the
skin temp to normalize
Assessing axiallry: has teh skin recently been washed? - correct
answer intervention: wait 1 hour after bathing before assessing
axiallry temp to allow time for the skin temp to noramlize or use
a different method
, Assessing Axillary: is the axilla moist or diaphoretic? - correct
answer intervention: use the other arm. use a different method.
or dry the axiallry region with a towel, using a patting motion
because perspiration causes inaccurate readings
Assessing axillary: are lesions, wounds, skin irritations or sore
present - correct answer use the other axilla or use a different
method because skin problems may raise temp.
Assessing rectal: is there a patient history of rectal surgery or
bleeding - correct answer intervention: rectal method is
contraindicated. avoid for risk of injury.
Assessing rectal: is the patient on an anticoagulant or having
diarrhea? - correct answer Intervention: use a different method,
avoid risk for bleeding, or stimulating bowel movements
Assessing rectal: are lesions, wounds, hemorrhoids or other
sores present? - correct answer Intervention: use different
mehtod to avoid risk for injury.
Assessing Tympanic: is there a history of recent or current ear
surgery or infection? - correct answer Intervention: use the
other ear, or different method
Assessing tympanic: are there hearing aids or personal stereo or
other listening devices in the ears? - correct answer
Intervention: use the other ear is one device is present, if 2
devices are present, remove one and wait 5 minutes before
taking the temp. these devices have retained heat inside the ear
canal, artifically making the temp higher. It takes at least 3
minutes for the ear canal to normalize its temp.
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