The nurse is caring for a client who has had an upper G.I. endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed assistant to take the vital signs. Two hours later, the assistant reports to client who was previously afebrile has now developed a temperature of 101.8°F. What should the nurse do in response to this reported data by the unlicensed assistant?

Promptly assess the client for a potential perforation

Tell the assistant to change thermometers and retake the temperature

Plan to give the client acetaminophen the lower temperature

Ask the assistant to bathe the client with tap water

Answer and Explanation

The Correct Answer is A

A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.

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Correct Answer is D

Explanation

A. Tympany upon chest percussion is typically associated with the presence of air, such as in cases of pneumothorax or gastric distention. It is not a typical finding in pneumonia.
B. Unequal pupils (anisocoria) are not a common symptom of pneumonia and may indicate a neurological issue rather than a respiratory infection.
C. Hypertension is not a characteristic finding in community-acquired pneumonia. Pneumonia may cause changes in blood pressure, but hypotension or normal blood pressure is more likely.
D. Confusion is a common finding in older adults with pneumonia. This can be due to factors such as hypoxia, dehydration, or infection-related changes in mental status, often referred to as "pneumonia delirium" or "acute confusion." Older adults are particularly susceptible to cognitive changes due to infection.

A. Night sweats B. Narrowed pulse pressure C. Confusion D. Bradycardia

Correct Answer is C

Explanation

A. Night sweats are more commonly associated with conditions like tuberculosis or certain cancers, rather than pneumonia, although they could occasionally be seen in severe pneumonia.
B. Narrowed pulse pressure is not a typical sign of pneumonia and is more indicative of conditions such as shock or heart failure.
C. Confusion is a classic and often overlooked symptom of pneumonia in older adults. Pneumonia in this population can present with altered mental status or confusion rather than typical respiratory symptoms like cough and fever.
D. Bradycardia is not a typical finding in pneumonia. In fact, tachycardia (an increased heart rate) is more commonly seen as the body tries to compensate for the infection.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

Correct Answer is C

Explanation

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