Nokea
The patient has a temperature of 105.2?°F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature?
- A. Radiation
- B. Conduction
- C. Convection
- D. Evaporation
Correct Answer: B
Rationale: Tepid sponge baths and cool compresses lower temperature via conduction (B), transferring heat from the skin to the cooler objects through direct contact. Radiation (A) involves heat loss to the environment without contact, not the primary method here. Convection (C) requires air movement (e.g., fans), not used. Evaporation (D) occurs with moisture vaporizing, a minor effect with tepid water but not dominant. Choice B is correct as conduction is the main mechanism, aligning with nursing interventions to reduce fever by physically drawing heat away from the body.
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The nurse needs to obtain an accurate respiratory rate from a patient who is talking with visitors. What will the nurse do?
- A. Tell the patient to continue talking.
- B. Count respirations while the patient is talking.
- C. Obtain without the patient knowing.
- D. Wait until the patient finishes talking.
Correct Answer: C
Rationale: Talking alters respiratory rate, so counting discreetly (C) during conversation ensures an undisturbed baseline. Continuing talking (A) or counting during it (B) skews results. Waiting (D) delays assessment. Choice C is correct, a nursing tactic to capture natural breathing patterns accurately.
Which statement correctly defines hyperthermia?
- A. Hyperthermia is a downward shift in the set point.
- B. Hyperthermia is an upward shift in the set point.
- C. Hyperthermia occurs when the body cannot reduce heat production.
- D. Hyperthermia results from a reduction in thermoregulatory mechanisms.
Correct Answer: C
Rationale: Hyperthermia is an uncontrolled rise in body temperature when heat production exceeds dissipation (C), often from external factors or exertion, not set-point shifts. A downward set-point shift (A) isn't hyperthermia. An upward shift (B) defines fever, not hyperthermia. Reduced mechanisms (D) may contribute but isn't the definition. Choice C is correct, distinguishing hyperthermia from fever per nursing pathophysiology, critical for appropriate interventions.
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.
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.
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.