Nokea
The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8?°F (36?°C), whereas at 4:00 PM the preceding day, it was 98.6?°F (37?°C). What should the nurse do?
- A. Call the health care provider immediately to report a possible infection.
- B. Administer medication to lower the temperature further.
- C. Provide another blanket to conserve body temperature.
- D. Wait 30 minutes and recheck the patient's temperature.
Correct Answer: D
Rationale: A temperature of 96.8?°F (36?°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck (D) confirms if it's a trend or artifact, avoiding overreaction. Calling the provider (A) is premature for a non-critical value without symptoms. Lowering it further (B) is illogical for hypothermia. Adding a blanket (C) assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.
You may also like to solve these questions
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.
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.
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 nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
- A. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.
- B. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist.
- C. Place the thumb over the groove along the little finger side of the patient's wrist.
- D. Place the thumb over the groove along the thumb side of the patient's wrist.
Correct Answer: A
Rationale: Radial pulse is palpated with the first two fingers along the thumb side groove (A), ensuring accuracy without thumb pressure interference. Little finger side (B, C) is incorrect anatomically. Thumb use (C, D) distorts readings. Choice A is correct, per nursing technique standards, for reliable radial pulse measurement.
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.