Nokea
The nurse needs to take the temperature of a patient who had a cardiac arrest. Which route will the nurse use?
- A. Oral
- B. Rectal
- C. Tympanic
- D. Temporal
Correct Answer: C
Rationale: Post-cardiac arrest, tympanic (C) provides a quick, non-invasive core temperature estimate, critical for monitoring hypothermia or hyperthermia in resuscitation. Oral (A) risks inaccuracy post-arrest. Rectal (B) is invasive and slow. Temporal (D) is less reliable in emergencies. Choice C is correct, aligning with ACLS emphasis on rapid, safe temperature assessment.
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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.
The nurse is caring for a patient whose condition is deteriorating and needs a pulse assessment. Which site should the nurse use?
- A. Radial
- B. Brachial
- C. Carotid
- D. Popliteal
Correct Answer: C
Rationale: In deteriorating patients, carotid (C) provides a strong, accessible pulse, reliable even in low perfusion, unlike radial (A) or brachial (B). Popliteal (D) is impractical. Choice C is correct, per emergency nursing standards (e.g., AHA), for critical pulse checks.
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.
A nurse is caring for a group of patients. Which patient will the nurse see first?
- A. A crying infant with P-165 and R-54
- B. A sleeping toddler with P-88 and R-23
- C. A calm adolescent with P-95 and R-26
- D. An exercising adult with P-108 and R-24
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 (A) is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler (B), adolescent (C), and adult (D) values are normal for context. Choice A is correct, per triage prioritizing potential instability.
When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action?
- A. It is not affected by skin moisture.
- B. It has no risk of injury to patient or nurse.
- C. It reflects rapid changes in radiant temperature.
- D. It is accurate even when the forehead is covered with hair
Correct Answer: B
Rationale: Temporal artery thermometers are non-invasive, posing no injury risk (B), ideal for newborns and children. Moisture (A) can affect accuracy. Radiant changes (C) are less relevant. Hair (D) interferes. Choice B is correct, per pediatric safety standards.