A nurse is observing an assistive personnel (AP) take a client’s tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?
A.
The AP inserts the probe with a straightforward motion.
B.
The AP positions the client facing her.
C.
The AP pulls the pinna up and back
D.
The AP points the probe posteriorly.
A nurse is observing an assistive personnel (AP) take a client’s tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?
A.
The AP inserts the probe with a straightforward motion.
B.
The AP positions the client facing her.
C.
The AP pulls the pinna up and back
D.
The AP points the probe posteriorly.
Answer and Explanation
The correct answer is:
C. The AP pulls the pinna up and back
Explanation:
When taking a tympanic temperature in a child over 1 year old or an adult, the proper technique is to pull the pinna (ear) up and back. This straightens the ear canal to ensure accurate measurement.
Here’s why the other options are less correct:
- A. The AP inserts the probe with a straightforward motion: Inserting the probe straightforwardly might not always be appropriate, especially in young children where the ear canal’s orientation needs adjustment.
- B. The AP positions the client facing her: The position of the client is less relevant to the accuracy of the tympanic temperature measurement compared to the technique of using the probe.
- D. The AP points the probe posteriorly: The probe should be aimed towards the tympanic membrane (eardrum), which means it should be directed towards the ear canal, not posteriorly.
Correct answer: C