A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C).
Which action should a nurse take next?
Notify the health care provider to report and anticipate new orders.
Cover the client with an additional blanket & alert the UAP to recheck in two hours.
Chart the temperature on the vital signs sheet and report to the new shift coming on.
Assess the client’s temperature rectally and compare the results.
The Correct Answer is A
Notify the health care provider to report and anticipate new orders.
This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.
A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.
Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.
Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.
The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.
Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.
The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.
Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.
Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.
The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should ask this question to support safe medication administration because the client is to receive medications that are highly teratogenic. Teratogens are substances that can cause congenital disorders and fetal abnormalities.
The nurse should avoid giving teratogenic medications to pregnant clients or clients who may become pregnant.
Choice A is wrong because the family history of cancer is not relevant to the teratogenic effects of the medications.
Choice C is wrong because the previous experience of severe side effects from a drug is not related to the risk of fetal harm.
Choice D is wrong because the allergy to any prescription or non-prescription drugs is not specific to the teratogenic potential of the medications.
Correct Answer is C
Explanation
This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.
This will also help contain the fire and prevent it from spreading.
Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.
Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.
Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.
Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.
The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.
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