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
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
Correct Answer is C
Explanation
This is because it shows a normal pH, pCO2, HCO3 and pO2, indicating that the treatment has been effective in restoring normal gas exchange and acid- base balance.
Choice A is wrong because it shows a low pH, high pCO2 and high HCO3, indicating a mixed respiratory and metabolic acidosis.
Choice B is wrong because it shows a low pH, high pCO2 and low HCO3, indicating a combined respiratory and metabolic acidosis.
Choice D is wrong because it shows a high pH, low pCO2 and low HCO3, indicating a mixed respiratory and metabolic alkalosis.
The normal ranges for arterial blood gas (ABG) are:
- pH: 7.35 – 7.45
- pO2: 10 – 14 kPa or 75 – 105 mmHg
- pCO2: 4.5 – 6 kPa or 34 – 45 mmHg
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