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 A
Explanation
“It wouldn’t have mattered what you had worn.” This response by a nurse is appropriate because it validates the client’s feelings and helps to reduce self-blame. It also conveys that rape is not caused by the victim’s clothing or behavior, but by the perpetrator’s violence and lack of respect.
Choice B. “The current styles are an invitation to disaster.” is wrong because it implies that the client is responsible for the rape and that she could have prevented it by dressing differently. This response is judgmental and insensitive, and may increase the client’s guilt and shame.
Choice C. “Never mind about blame.
That will be determined by the court.” is wrong because it dismisses the client’s feelings and does not address her emotional needs.
It also suggests that the nurse does not believe the client or support her. This response may make the client feel isolated and distrustful.
Choice D. “Some people don’t have very good self-control.
We have to help them all we can.” is wrong because it excuses the perpetrator’s behavior and shifts the blame to the victim.
It also implies that rape is a result of sexual desire, rather than an act of violence and domination. This response may make the client feel powerless and helpless.
Correct Answer is A
Explanation
Two 4x4 gauze cloths saturated with purulent drainage. This statement provides the best documentation of the amount of wound drainage because it specifies the size and number of gauze cloths, the type and amount of exudate, and the presence of infection
Choice B is wrong because it does not indicate the size or number of dressings, the type or amount of exudate, or the presence of infection.
Choice C is wrong because it does not indicate the size or number of dressings, the type of exudate, or the presence of infection.
Choice D is wrong because it does not indicate the size or number of dressings, the type of exudate, or the presence of infection.
Normal ranges for wound drainage are categorized as scant, minimal, moderate, or large/copious The type of wound drainage can be described as serous, sanguineous, serosanguineous, or purulent
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