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After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?
- A. Temperatures vary depending on the route used.
- B. Temperatures are readings of core measurements.
- C. Rectal temperatures are cooler than when taken orally.
- D. Axillary temperatures are higher than oral temperatures.
Correct Answer: A
Rationale: Temperature varies by route (A) e.g., rectal is 1?°F higher, axillary 1?°F lower than oral requiring documentation for accuracy. Not all are core (B). Rectal is warmer (C incorrect). Axillary is lower (D incorrect). Choice A is correct, per nursing documentation standards.
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The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient's temperature?
- A. Oral
- B. Rectal
- C. Axillary
- D. Tympanic
Correct Answer: D
Rationale: For a confused, agitated patient with seizures, tympanic (D) is safest and fastest, avoiding oral risks (biting) or rectal invasiveness (agitation, seizure risk). Oral (A) is unreliable with agitation. Rectal (B) risks injury or vagal stimulation. Axillary (C) is slow and less accurate. Choice D is correct, per nursing safety protocols, balancing accuracy and patient stability.
The nurse is caring for an older-adult patient and notes that the temperature is 96.8?°F (36?°C). How will the nurse interpret this?
- A. This is normal for an older adult.
- B. This is too high for an older adult.
- C. This is indicative of infection.
- D. This requires immediate intervention.
Correct Answer: A
Rationale: Older adults often have lower baseline temperatures (e.g., 96.8?°F) due to slower metabolism; (A) is normal. Too high (B) or infection (C) doesn't fit without symptoms. Intervention (D) is unnecessary. Choice A is correct, per geriatric nursing norms.
The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate?
- A. The patient has a fever.
- B. The patient has possible hemorrhage or bleeding.
- C. The patient has chronic obstructive pulmonary disease (COPD).
- D. The patient has calcium channel blockers or digitalis medication prescriptions.
Correct Answer: D
Rationale: A pulse of 48 (bradycardia) with normal BP suggests a cause like medications. Calcium channel blockers or digitalis (D) slow heart rate, a common side effect. Fever (A) increases pulse. Hemorrhage (B) lowers BP, not seen here. COPD (C) doesn't typically cause bradycardia. Choice D is correct, per pharmacology and nursing assessment principles.
The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse?
- A. Radial
- B. Brachial
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: In infants, the brachial artery (B) is preferred for pulse due to accessibility and strength; radial (A) is weak and hard to palpate. Femoral (C) and popliteal (D) are less practical. Choice B is correct, per pediatric norms, ensuring accurate infant pulse assessment.
The nurse is preparing to assess the blood pressure of a 3 year old. How should the nurse proceed?
- A. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds.
- B. Obtain the reading before the child has a chance to 'settle down.'
- C. Choose the cuff that says 'Child' instead of 'Infant.'
- D. Explain the procedure to the child.
Correct Answer: D
Rationale: For a 3-year-old, explaining the procedure (D) reduces anxiety, improving cooperation. Diaphragm (A) is less effective than the bell for Korotkoff sounds. Pre-settling (B) risks agitation. Child cuff (C) is correct but secondary. Choice D is correct, per pediatric nursing communication strategies.