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 ["E"]
Explanation
A private room with negative air pressure is required to care for a client with suspected or confirmed tuberculosis (TB) disease, as this is part of the airborne precautions recommended by the CDC.
A private room with negative air pressure prevents the spread of infectious droplet nuclei that contain the TB bacteria.
Choice A is wrong because gloves, masks, and gowns are not sufficient to protect against TB transmission.
Gloves and gowns are used for contact precautions, which are not indicated for TB.
A regular mask is also not effective in filtering out the small droplet nuclei that carry the TB bacteria.
Choice B is wrong because an N95 mask is not a precaution for the client, but for the healthcare personnel who are in close contact with the client.
An N95 mask is a type of respirator that can filter out at least 95% of airborne particles, including TB bacteria. Health care personnel should wear an N95 mask when entering the client’s room or performing aerosol-generating procedures on the client.
Choice C is wrong because droplet precautions are not indicated for TB.
Droplet precautions are used for infections that are spread by large respiratory droplets that do not remain suspended in the air, such as influenza or pertussis. Droplet precautions require wearing a regular mask and eye protection when within 6 feet of the client.
Choice D is wrong because contact precautions are not indicated for TB.
Contact precautions are used for infections that are spread by direct or indirect contact with the client or the client’s environment, such as Clostridium difficile or MRSA. Contact
Correct Answer is B
Explanation
Using teach back method to assess understanding. This method involves asking the client to repeat back the information or demonstrate the skill that was taught, which helps to evaluate their comprehension and retention.
It also allows the nurse to correct any misunderstandings and reinforce key points.
Choice A is wrong because teaching handouts are written on an eighth grade reading level may not be appropriate for older adult clients who may have lower literacy levels or cognitive impairments. The nurse should use simple, common language and large-print handouts that reflect the verbal information presented.
Choice C is wrong because the teaching plan is based on nutrition, medications, and safety may not address the individual needs and preferences of the older adult clients. The nurse should consider the preadmission functional abilities, health goals, and learning styles of each client when developing the plan of care.
Choice D is wrong because websites, video chats, and cell phone applications are introduced for learning may not be suitable or accessible for older adult clients who may have limited technology skills or sensory impairments. The nurse should use visual aids, face-to-face communication, and written instructions to enhance learning.
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