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    Hesi rn med surg proctored exam

    The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

    Explanation & Rationale

    A. Advise the UAP to hold the thermometer securely in place for a full three minutes is incorrect because tympanic thermometers provide quick readings, typically within a few seconds, and do not require prolonged placement. B. Use positive reinforcement to affirm that the procedure is being performed correctly is the correct action. For adult clients, the auricle should be pulled up and back to straighten the ear canal for accurate tympanic temperature measurement. Positive reinforcement supports the UAP's learning and confidence. C. Demonstrate the correct technique for pulling the client's auricle down and back is incorrect for adult clients. Pulling the auricle down and back is appropriate for children under 3 years old, not adults. D. Remind the UAP to lubricate the thermometer before gently inserting in the ear is not appropriate. Tympanic thermometers do not require lubrication, as they are designed for non-invasive and quick use.

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