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

Answer and Explanation

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).

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Correct Answer is B

Explanation

A. Advocacy. Advocacy involves protecting a client’s rights, ensuring informed decision-making, and speaking up for patient safety. While advocating for patient well-being is crucial, this scenario primarily reflects the nurse’s responsibility for their own actions rather than advocating for the client.

B. Accountability. Accountability means taking responsibility for one’s actions, including errors, and following appropriate steps to address them. By assessing the client, informing the provider, and completing an incident report, the nurse demonstrates professional integrity and commitment to ethical practice.

C. Fairness. Fairness involves treating all patients equitably and ensuring unbiased care. While important in nursing, fairness does not directly apply to this situation, which centers on taking responsibility for an error rather than distributing care impartially.

D. Confidence. Confidence refers to the nurse’s self-assurance in clinical decision-making and skills. While confidence is essential in nursing practice, admitting and reporting an error requires integrity and accountability rather than confidence.

A. "There are four steps in the process of EBP." B. "Reviewing the effectiveness of the findings is the last step of the EBP process." C. "Reliance on personal experiences is important to the process of EBP" D. "Identifying the problem is the first step of the EBP process."

Correct Answer is B

Explanation

A. "There are four steps in the process of EBP." The evidence-based practice (EBP) process generally consists of six to seven steps, including identifying a clinical problem, formulating a clinical question, searching for relevant evidence, appraising the evidence, integrating findings into practice, evaluating outcomes, and disseminating results. Stating that there are only four steps is inaccurate.

B. "Reviewing the effectiveness of the findings is the last step of the EBP process." The final step in EBP involves evaluating whether the implemented practice changes were effective in improving patient outcomes. If the findings are not beneficial, modifications or additional research may be necessary. This statement correctly reflects the last step of EBP.

C. "Reliance on personal experiences is important to the process of EBP." While clinical experience can inform decision-making, EBP prioritizes high-quality, peer-reviewed research and objective data rather than solely relying on personal experiences, which may be biased or outdated.

D. "Identifying the problem is the first step of the EBP process." The first step in EBP is typically forming a well-structured clinical question using frameworks such as PICO (Population, Intervention, Comparison, Outcome). Identifying a general problem is an early stage but is refined into a researchable question before proceeding.

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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?

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