A nurse is assessing a client who has an oral temperature of 39° C (102.2° F). Which of the following findings should the nurse expect?
Decreased peripheral pulses
Dilated pupils
Respiratory rate 10/min
Heart rate 108/min
The Correct Answer is D
A. Decreased peripheral pulses. Fever leads to vasodilation and increased cardiac output, which generally enhances peripheral blood flow. As a result, peripheral pulses are more likely to be strong and bounding rather than decreased.
B. Dilated pupils. Pupil dilation is associated with sympathetic nervous system activation, often due to stress, fear, or certain medications. Fever alone does not typically cause pupil dilation, making this an unlikely expected finding.
C. Respiratory rate 10/min. Fever usually increases metabolic demand, leading to a higher respiratory rate (tachypnea) rather than a lower one. A respiratory rate of 10 breaths per minute would be considered bradypnea, which is not a typical response to fever.
D. Heart rate 108/min. Fever stimulates the sympathetic nervous system, increasing heart rate (tachycardia) to meet the body’s higher metabolic and oxygen demands. A heart rate of 108/min is expected in response to a fever of 39°C (102.2°F).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Fairness. Fairness involves providing equitable and unbiased care to all patients. While fairness is a crucial aspect of nursing ethics, checking a client’s response to pain medication is more aligned with the nurse’s duty to follow through on patient care responsibilities.
B. Confidence. Confidence refers to a nurse’s self-assurance in their clinical skills and decision-making. Although confidence is important in nursing practice, evaluating a medication’s effectiveness is more about fulfilling a professional duty rather than demonstrating confidence.
C. Responsibility. Responsibility involves following through on nursing interventions and ensuring patient safety. By checking on the client to evaluate the effectiveness of a pain medication, the nurse is demonstrating accountability for patient care and adherence to proper nursing practice.
D. Advocacy. Advocacy involves speaking up for a patient’s rights, ensuring they receive appropriate care, and supporting their well-being. While assessing pain relief can contribute to advocacy, in this case, the nurse is primarily fulfilling their professional responsibility in medication administration and follow-up.
Correct Answer is C
Explanation
A. TJC is an organization that monitors insurance claims. The Joint Commission does not oversee insurance claims or reimbursement processes. Its primary role is to evaluate and accredit healthcare organizations to ensure they meet safety and quality standards.
B. TJC provides licensure for health care providers. TJC does not issue professional licenses; this is the responsibility of state licensing boards and regulatory agencies. Instead, TJC focuses on accrediting healthcare organizations to ensure they meet established quality and safety standards.
C. TJC provides accreditation to facilities. The Joint Commission accredits hospitals, long-term care facilities, and other healthcare organizations, ensuring they meet national patient safety and quality standards. Accreditation by TJC signifies compliance with best practices and can impact funding and reputation.
D. TJC is a for-profit organization. TJC is a non-profit organization that works to improve healthcare quality and safety. Its accreditation process is designed to promote excellence in patient care rather than generate profits.
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