Fundamentals of Nursing Q 372
The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?
A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape
Correct Answer: B. Axillary
Axilla is the most accessible body part in this situation. Body temperature is a numerical expression of the body’s heat and metabolic activity balance and can be a major indicator of a person’s health status. Assessing a patient’s body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic distress.
Option A: The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin, flexible catheter that has a rounded tip that should be lubricated with water-soluble lubricant before being placed through the nares or mouth, extending into the esophagus at least 2 to 3 in (5 to 7.6 cm). The external end portion of the catheter has a small, coated wire with a plug that can be attached to a telemetry monitor for continuous temperature monitoring.
Option C: The ETP and RTP (rectal temperature probe) are the same device but can be used in either orifice depending on the patient’s medical condition. Again, the tip should be lubricated with water-soluble lubricant, and then placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also be attached to a telemetry monitor cable for continuous temperature monitoring.
Option D: This is a latex-free, disposable, adhesive strip that can be applied to the forehead. These strips contain embedded liquid crystals and chemical compounds that react to the temperature (heat) of the skin by changing colors. After it has been on the forehead for approximately 2 minutes, the color will illuminate a line and correlate numeric temperature. The strips measure temperatures ranging from 96.6[degrees] F to 104.6[degrees] F (35.8[degrees] C to 40.3[degrees] C). Consider use for infants, children, and adults with cognitive deficits because they’re painless.