Page 298 - Saunders Comprehensive Review For NCLEX-RN

is used when the oral or other methods
of temperature measurement are
contraindicated.
b. Axillary measurement is not as accurate
as the oral, rectal, tympanic, or
temporal artery method but is used
when other methods of measurement
are not possible.
c. The thermometer is placed in the
client’s dry axilla, and the client is
asked to hold the arm tightly against
the chest, resting the arm on the chest;
follow the instructions accompanying
the measurement device for the
amount of time the thermometer
should remain in the axillary area.
4. Tympanic

a. The auditory canal is checked

for the presence of redness, swelling,
discharge, or a foreign body before the
probe is inserted; the probe should not
be inserted if the client has an
inflammatory condition of the auditory
canal or if there is discharge from the
ear.
b. The reading may be affected by an ear
infection or excessive wax blocking the
ear canal.
5. Temporal artery
a. Ensure that the client’s forehead is dry.
b. The thermometer probe is placed flush
against the skin and slid across the
forehead or placed in the area of the
temporal artery and held in place.
c. If the client is diaphoretic, the temporal
artery thermometer probe may be
placed on the neck, just behind the
earlobe.
III. Pulse
A. Description
1. Pulse is a palpable bounding of blood flow in a
peripheral artery; it is an indirect indicator of
circulatory status.
2. The average adult pulse (heart) rate is 60 to 100 beats
per minute.
3. Changes in pulse rate are used to evaluate the client’s
tolerance of interventions such as ambulation,

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