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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.
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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.
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.
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
- A. Stethoscope
- B. Thermometer
- C. Blood pressure cuff
- D. Sphygmomanometer
Correct Answer: B
Rationale: Pyrexia (fever) requires temperature monitoring, making a thermometer (B) essential. A stethoscope (A) assesses heart/lung sounds, not temperature. A blood pressure cuff (C) or sphygmomanometer (D) measures pressure, not fever. Choice B is correct as thermometers directly track temperature changes, a fundamental tool in nursing to manage and document febrile states accurately.
The patient is lying in bed under a ceiling fan. Which technique is the nurse using when the fan produces heat loss?
- A. Radiation
- B. Conduction
- C. Convection
- D. Evaporation
Correct Answer: C
Rationale: A ceiling fan moves air over the patient, causing heat loss via convection (C), where warm air around the body is replaced by cooler moving air. Radiation (A) involves heat emission without contact, not fan-driven. Conduction (B) requires direct contact (e.g., cold pack), not air movement. Evaporation (D) involves moisture loss, not primarily fan-related here. Choice C is correct because convection matches the mechanism of air circulation enhancing heat dissipation, a principle nurses apply in thermoregulation strategies to cool patients effectively in clinical settings.
The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next?
- A. Ask the NAP to retake the blood pressure.
- B. Instruct the NAP to assess the patient's other vital signs.
- C. Disregard the report and have it rechecked at the next scheduled time.
- D. Retake the blood pressure personally and assess the patient's condition
Correct Answer: D
Rationale: Abnormally low BP requires verification and assessment. The nurse retaking it (D) ensures accuracy and allows immediate patient evaluation, overriding NAP data. Retaking by NAP (A) or adding vitals (B) delays RN judgment. Ignoring it (C) risks harm. Choice D is correct, per RN accountability standards.