The nurse has assigned nursing assistive personnel to obtain the tempe

The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit’s clients.

Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally?
1. “Are all the clients cooperative enough to take the temperatures orally?”
2. “Do you want me to take the temperature tympanically on everyone?”
3. “I’ll wait until breakfast is over so I won’t distract them from eating.”
4. “I’ll chart the results and let you know whose temperature is running high.”

ANSWER

ANS: 3
When taking oral temperature, wait 20 to 30 min before measuring temperature if the client has smoked or ingested hot or cold liquids or foods. The nurse needs to reinforce this information so that the assessment will occur before breakfast or to allow enough time to pass after breakfast so as not to affect the readings. The options containing a question reflect a need for knowledge but do not have priority over an obvious indication of possible poor assessment technique. The nurse needs to evaluate the readings and so should be sure to give the assistive personnel guidance as to what readings are “running high.”