Answer: d. Rectal Explanation: The rectal route provides the most accurate measurement of core body temperature as it reflects the temperature of blood perfusing the hypothalamus, which regulates body temperature.

a. The oral route is commonly used and provides a convenient method for temperature measurement but may be influenced by oral intake and respiratory route, making it slightly less accurate.

b. The axillary route is less invasive and easier to use, but it tends to underestimate core body temperature.

c. The temporal route provides a quick measurement but may not be as accurate as the rectal route, especially in certain populations.

Answer: b. Document the temperature and continue monitoring. Explanation: A temperature reading of 102°F (38.9°C) indicates a fever but does not require immediate intervention unless accompanied by other significant symptoms or in certain high-risk populations. The nurse should document the temperature and continue monitoring the client's condition.

a. Administering antipyretic medication may be appropriate based on the client's symptoms and healthcare provider's orders, but it is not the immediate action for a single temperature reading of 102°F.

c. Applying cool compresses can provide comfort to the client but does not address the underlying cause of the fever.

d. Notifying the healthcare provider immediately is not necessary based solely on a temperature reading of 102°F without other significant symptoms or concerns.

Answer: d. Position the thermometer in the client's ear canal.

Explanation: Tympanic thermometers are used by positioning the thermometer in the client's ear canal to obtain an accurate measurement of body temperature.

a. Placing the thermometer in the mouth is appropriate for oral temperature measurement but not for tympanic thermometers.

b. Inserting the thermometer into the rectum is appropriate for rectal temperature measurement but not for tympanic thermometers.

c. Aiming the thermometer at the forehead is appropriate for temporal artery thermometers but not for tympanic thermometers.

Answer: c. 20 seconds

Explanation: To obtain an accurate reading using an electronic thermometer, the nurse should leave the thermometer in place for approximately 20 seconds or as recommended by the manufacturer's instructions.

a. 5 seconds is typically not sufficient to obtain an accurate reading with an electronic thermometer.

b. 10 seconds may be sufficient for certain electronic thermometers, but 20 seconds is generally recommended for accuracy.

d. 1 minute is longer than necessary for most electronic thermometers and may not provide any additional benefit in terms of accuracy.

Answer: a. Cover the client with warm blankets.

Explanation: Shivering and goosebumps are signs of the body's attempt to increase body temperature. The nurse should cover the client with warm blankets to prevent heat loss and promote comfort.

b. Administering an antipyretic medication is not appropriate in this scenario as shivering and goosebumps indicate the body's attempt to increase body temperature, not fever.

c. Applying cool compresses is not appropriate when the client is experiencing shivering and goosebumps, as the goal is to prevent heat loss.

d. Notifying the healthcare provider immediately is not necessary based on shivering and goosebumps alone, as they are normal physiological responses to cold or low body temperature.