Question

The nurse collects patient data through assessment of vital signs. Many nurses will delegate the performance of temperature data collection to unlicensed assistive personnel. As the nurse talks to the assistant, the nurse knows to teach that:

A) Tympanic thermometers touch the tympanic membrane.
B) Axillary temperatures are taken with the red probe on the electronic thermometer.
C) Axillary temperatures are usually most accurate because of the local blood supply.
D) Rectal thermometers are placed 2.8 cm to 3.5 cm into the rectum.

Answer 1

The nurse should explain that tympanic thermometers measure infrared radiation and do not touch the tympanic membrane. Axillary temperatures are less accurate and the red probe is about technique, not accuracy. Correctly inserted rectal thermometers provide accurate readings.

Step-by-step explanation:

The nurse must ensure that proper techniques are used when delegating the task of collecting temperature data to unlicensed assistive personnel. It's important to clarify that:

• Tympanic thermometers do not touch the tympanic membrane directly but measure the infrared radiation emitted by it. This technology was developed by Diatek Corporation and NASA for quick and non-invasive temperature measurements.
• Axillary temperatures are not usually the most accurate due to the location; thus, the red probe statement is a technique-related instruction rather than an indicator of accuracy. In fact, tympanic and digital methods often provide more precise readings.
• When using rectal thermometers, they should be inserted 2.8 cm to 3.5 cm into the rectum for an adult to ensure an accurate reading.

Understanding the importance of accuracy in vital sign assessment can help in early detection and management of potential illnesses.