Question

The nurse has received a report from unlicensed assistive personnel in relation to the morning vital signs. Which statement would indicate that the oral temperature method is contraindicated in this client?

Answer 1

The choices are:

a. "The client is exhibiting persistent coughing."

b. "The client has passed three stools since morning."

c. "The client was on oxygen when I took the reading."

d. "The client has recently undergone rectal surgery.

Answer:

The answer is letter c.

Explanation:

There are many ways of taking a patient's temperature. This can be done orally, temporally and rectally (although there are already modern ways to get the temperature). These were considered the classical methods.

If the temperature of the patient has to be taken orally, it is important to consider the following:

• It should not be used in patients who have seizures.
• It should not be used in infants and young children.
• It should not be used in patients who have mouth surgeries.
• It should not be used in patients who have Oxygen masks (the Oxygen is cold, thus it can alter the temperature reading).

The unlicensed assistive personnel says that he took the oral temperature of the patient while he was on oxygen. This is clearly one of the contraindications I mentioned above.

Thus, this explains the answer, letter c.