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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The hypothalamus is the primary center for thermoregulation. When a client sustains a head injury, especially involving the hypothalamus or brainstem, the body may lose its ability to properly regulate temperature. This can lead to a neurogenic fever, which is a non-infectious fever caused by damage to the thermoregulatory center.
Rationale for correct answer:
D. Ineffective thermoregulation: This nursing diagnosis reflects an actual disruption in temperature regulation due to neurological impairment. It encompasses both fever and hypothermia, making it the most comprehensive and accurate for this client.
Rationale for incorrect answers:
A. Risk for imbalanced body temperature: This diagnosis is used when the risk factors are present, but the condition has not yet occurred.
B. Hyperthermia refers to an elevated body temperature due to external heat or failure of heat loss mechanisms (e.g., heatstroke, environmental exposure).
C. Hypothermia is defined as a core body temperature below 35°C (95°F). There’s no indication that the client is hypothermic, and with the mention of neurogenic fever, the temperature is expected to increase, not decrease.
Take-home points:
- Ineffective thermoregulation is the most appropriate nursing diagnosis for clients with neurologically driven temperature abnormalities, such as neurogenic fever.
- Nurses must differentiate between external causes of hyperthermia and central (neurogenic) causes, especially in clients with head injuries.
Correct Answer is C
Explanation
In cases where a client presents with acute symptoms, the nurse must use clinical judgment to determine whether vital sign assessment requires nursing-level evaluation, particularly for parameters that require observation, interpretation, or correlation with clinical symptoms.
Rationale for correct answer:
C. Respiratory rate is the most sensitive indicator of deterioration and must often be assessed by a nurse, especially in clients with dyspnea or altered mental status.
Rationale for incorrect answers:
A. Temperature: Taking temperature is a simple, objective task that is appropriate to delegate to trained personnel.
B. Pulse can generally be delegated, especially when using automated equipment.
D. Blood Pressure is usually safe to delegate to trained personnel. While the nurse should evaluate the results, the act of measuring BP (especially with an automated device) does not require advanced assessment skills unless there's an abnormality.
Take-home points:
- Respiratory rate is often under-assessed but is critical for identifying early clinical deterioration, especially in clients with dyspnea or confusion.
- Delegation decisions must always factor in client stability, the complexity of the task, and the skill level required to interpret findings.
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