Before obtaining an axillary temperature, the nurse should perform which action?

Before obtaining an axillary temperature, the nurse should perform which action?

• A. Check the last oral temperature reading
• B. Position the client's arm at heart level
• C. Ask when the client last ate or drank
• D. Place a protective sheath over the thermometer

Answer: (D)

Infection control and device hygiene are essential when taking temperatures. Placing a protective sheath over the thermometer creates a single-use barrier between the device and the patient’s skin, preventing cross-contamination and protecting both the patient and the nurse. This precaution is performed before obtaining the reading to ensure a clean, safe measurement every time, regardless of the route used. The other actions aren’t necessary pre-measurement for an axillary temperature: knowing when the patient last ate or drank isn’t required for this route, and positioning the arm at heart level isn’t part of the axillary technique.

Infection control and device hygiene are essential when taking temperatures. Placing a protective sheath over the thermometer creates a single-use barrier between the device and the patient’s skin, preventing cross-contamination and protecting both the patient and the nurse. This precaution is performed before obtaining the reading to ensure a clean, safe measurement every time, regardless of the route used. The other actions aren’t necessary pre-measurement for an axillary temperature: knowing when the patient last ate or drank isn’t required for this route, and positioning the arm at heart level isn’t part of the axillary technique.