Fundamentals of Nursing Q 395
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?
A. Oral
B. Axillary
C. Arterial line
D. Rectal
Correct Answer: B. Axillary
Taking the temperature via the axilla is the most appropriate route. 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: Taking the temperature via the oral route is incorrect since the client had oral surgery. 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: A PiCCO thermodilution catheter (Pulsion Medical Systems) containing a temperature thermistor was inserted into the brachial artery at the antecubital fossa and doubled as the arterial pressure monitoring line and arterial blood sampling portal. This measured brachial artery temperature from the time of insertion to the time the patient left the operating room.
Option D: This is unnecessary. 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.