The client’s temperature at 8:00 am using an oral electronic thermometer is 3F.1°C (97.2°F). If the respiration, pulse, and blood pressure were within normal range, what would the nurse do next?
Wait 15 minutes and retake it.
Check what the client’s temperature was the last time it was taken.
Retake it using a different thermometer.
Chart the temperature; it is normal.
The Correct Answer is B
Vital signs provide critical information about a client's physiological status. When evaluating temperature, it's essential to consider normal ranges, the client’s baseline, and potential factors affecting the measurement (e.g., equipment error, recent food or fluid intake).
Rationale for correct answer:
B. Check what the client’s temperature was the last time it was taken: A single temperature reading may be normal or abnormal depending on the client's baseline pattern. Comparing previous readings helps determine whether this value is consistent or a new finding that might warrant further assessment.
Rationale for incorrect answers:
A. Wait 15 minutes and retake it: There is no indication that the initial temperature was affected by recent activity such as eating, drinking, or smoking, which could temporarily alter an oral temperature.
C. Retake it using a different thermometer: There’s no indication that the equipment is malfunctioning. If the reading had been inconsistent with the client’s condition, or if the thermometer showed an error, retaking with a different device would be reasonable.
D. Chart the temperature; it is normal: While 3F.1°C (97.2°F) is technically within the lower limit of normal, this option skips an important clinical validation step: checking for trends. The nurse may miss a developing pattern of hypothermia or a declining trend in temperature.
Take-home points:
- Always compare current vital signs with the client’s baseline and trends to determine clinical significance.
- Low-normal temperature readings require context- never assume they're acceptable without reviewing previous data and clinical presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Accurate blood pressure (BP) measurement is a fundamental nursing skill. If the cuff is deflated too quickly, the nurse may miss the first Korotkoff sound (systolic BP) or inaccurately estimate diastolic pressure. Deflating the cuff too slowly can cause venous congestion, discomfort, and a falsely high diastolic reading. Best practice guidelines recommend a cuff deflation rate of 2–3 mmHg per second to ensure an accurate reading without patient discomfort.
Rationale for correct answer:
B. 30–45 seconds: This is the recommended time frame for releasing the cuff when using a 2–3 mmHg/second deflation rate, which allows clear identification of both systolic and diastolic sounds.
Rationale for incorrect answers:
A. 10–20 seconds: Deflating the cuff this quickly equates to a deflation rate that is too fast (greater than 5 mmHg per second). This may result in missing Korotkoff sounds and underestimating the true BP values, especially systolic pressure.
C. 1 -- A.5 minutes: Deflating the cuff this slowly would equate to less than 1 mmHg per second, which is unnecessarily prolonged. It can cause venous congestion, discomfort, and may lead to a falsely elevated diastolic pressure.
D. 3–C.5 minutes: This is excessively slow and not clinically appropriate.
Take-home points:
- The blood pressure cuff should be deflated at a rate of 2-3 mmHg per second, resulting in a total release time of approximately 30-45 seconds, depending on the pressure range.
- Incorrect deflation rates (too fast or too slow) can lead to inaccurate readings and impact clinical decisions.
Correct Answer is A
Explanation
According to guidelines like JNC 7 and ACC/AHA, consistent elevated readings over multiple visits are necessary to diagnose hypertension. Nurses play a vital role in recognizing abnormal readings, educating patients, and guiding appropriate follow-up to prevent long-term complications like stroke or heart disease.
Rationale for correct answer:
A. Follow-up measurements of blood pressure: A single elevated BP does not confirm a diagnosis of hypertension. The nurse should recommend rechecking BP on separate occasions, as per guidelines, to determine if the elevation is persistent.
Rationale for incorrect answers:
B. Immediate treatment by a physician: Immediate treatment is not warranted based on a single mildly elevated BP unless the patient is symptomatic or has evidence of organ damage.
C. Nothing, because the nurse considers this reading is due to anxiety: While anxiety (white-coat hypertension) may cause temporary elevation, it should not be assumed without confirmation.
D. A change in dietary intake: Dietary changes (e.g., low sodium, DASH diet) are important in preventing or managing hypertension. However, before prescribing lifestyle changes, the first step is to confirm whether BP is consistently elevated.
Take-home points:
- A single reading of 130/90 mm Hg should prompt follow-up measurements, not immediate diagnosis or treatment.
- Nurses should avoid assumptions and use evidence-based protocols to guide BP assessment and education.
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