Difficulty: Medium
Average Score: 86%
Simulated
A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?
Correct answer
A
Rationale
The correct answer is A: Wait 30 min and return to measure the client's oral temperature. When a client consumes ice chips, it can significantly lower their oral temperature, leading to an inaccurate reading. Waiting for 30 minutes allows the ice chips to melt and the oral temperature to stabilize. Providing warm water (choice B) may not be effective in raising the oral temperature quickly enough for an accurate reading. Documenting the inability to obtain an accurate reading (choice C) is not proactive in ensuring accurate assessment. Proceeding to measure the client's oral temperature (choice D) without allowing time for the ice chips to melt will likely result in an inaccurate reading.