A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

Decreased peripheral pulses

Heart rate 108/min

Respiratory rate 10 breathes/min

Dilated pupils

Answer and Explanation

The Correct Answer is B

A) Decreased peripheral pulses:
Increased body temperature typically causes vasodilation rather than vasoconstriction, leading to improved blood flow rather than decreased. As a result, peripheral pulses are more likely to be normal or even increased in response to fever. Decreased peripheral pulses would be more indicative of conditions like shock or hypoperfusion, not fever.

B) Heart rate 108/min:
Fever causes an increase in metabolic demand, which often results in a compensatory increase in heart rate (tachycardia). This phenomenon, known as "fever tachycardia," occurs as the body attempts to circulate blood more rapidly to meet the increased oxygen and nutrient demands caused by elevated body temperature. A heart rate of 108 beats per minute is a normal response to fever, particularly when the temperature reaches 39°C (102.27°F).
C) Respiratory rate 10 breaths/min:
A respiratory rate of 10 breaths per minute is considered bradypnea (abnormally slow breathing), which is typically not associated with fever. Fever usually leads to an increase in respiratory rate (tachypnea) as the body attempts to cool itself through increased evaporation of sweat and breathing. A respiratory rate of 10 breaths/min is more likely to be seen in conditions like drug overdose, head injury, or respiratory depression, rather than fever.
D) Dilated pupils:
Dilated pupils (mydriasis) are typically associated with sympathetic nervous system activation, which can be caused by certain drugs, trauma, or neurological conditions. Fever, however, generally causes only mild changes in pupil size and is more likely to lead to constricted pupils (miosis) in response to certain stress hormones. Dilated pupils are not a typical finding with fever.

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Correct Answer is B

Explanation

A) Orange juice:
Orange juice is generally safe to consume with most medications and does not pose significant risks like grapefruit juice. It is a good source of vitamin C and typically does not interact with prescription medications in a harmful way. However, some medications, particularly those for high blood pressure or heart conditions, may have specific instructions regarding food interactions.

B) Grapefruit juice:
Grapefruit juice should be avoided by clients taking certain medications, as it can interfere with the metabolism of various drugs. Grapefruit contains compounds that inhibit the action of the enzyme cytochrome P450 3A4, which plays a crucial role in metabolizing many medications. This can lead to higher levels of the drug in the bloodstream, increasing the risk of adverse effects or toxicity. Medications commonly affected include certain statins, calcium channel blockers, and immunosuppressants, among others.

C) Milk:
Milk is generally safe to consume with most medications, though it can interfere with the absorption of certain drugs, such as tetracycline antibiotics or some bisphosphonates (used for osteoporosis). However, milk is not as commonly problematic as grapefruit juice and is not a major concern for most prescription medications.

D) Carbonated beverage:
Carbonated beverages, such as soda, do not typically interact with most medications in a way that would cause harm. However, some carbonated drinks can cause gastrointestinal discomfort, especially when taken with certain medications that affect the stomach or intestines.

A. The client who has a nasogastric (NG) tube to suction B. The client who has a chest tube to water seal C. The client who has an indwelling urinary catheter to gravity drainage D. The client who has a tracheostomy tube attached to humidified oxygen

Correct Answer is A

Explanation

A) The client who has a nasogastric (NG) tube to suction:
A nasogastric (NG) tube that is used for suction can lead to the loss of gastric fluids, which are rich in potassium. Prolonged suctioning can cause the client to lose significant amounts of potassium, putting them at risk for hypokalemia. Potassium is an essential electrolyte that is vital for proper muscle and nerve function, and its loss can result in symptoms such as weakness, arrhythmias, and fatigue.

B) The client who has a chest tube to water seal:
A chest tube to water seal is used to drain air or fluid from the pleural space, typically following surgery or trauma. While chest tube drainage can lead to fluid loss, it is not directly associated with significant electrolyte imbalances like hypokalemia. The primary concern with chest tubes is fluid balance and preventing infection, but it does not specifically cause potassium loss unless there are other contributing factors, such as excessive diuresis or vomiting.

C) The client who has an indwelling urinary catheter to gravity drainage:
An indwelling urinary catheter primarily allows for the drainage of urine, and while it may contribute to fluid and electrolyte loss (especially if there is excessive urination or diuresis), it is not directly linked to hypokalemia unless the client is receiving medications (e.g., diuretics) that cause potassium loss through urine. The catheter itself does not significantly increase the risk of hypokalemia unless other factors are involved.

D) The client who has a tracheostomy tube attached to humidified oxygen:
A tracheostomy tube attached to humidified oxygen helps with respiratory support and does not directly affect potassium levels. The primary concern with tracheostomies is airway management, preventing infection, and ensuring proper oxygenation. It is not associated with electrolyte imbalances such as hypokalemia. However, if the client experiences issues such as excessive fluid loss through respiratory secretions or complications like infection, it could indirectly affect electrolyte levels, but it is not a direct cause of hypokalemia.

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A nurse is assessing a client who has an oral temperature of 39 C (102.27 F). Which of the following findings should the nurse expect?

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