The nurse is caring for a patient who collapsed after working outside on a hot day. The patient is disoriented with hot, dry skin and a heart rate of 140 beats/minute. Which temperature will the nurse expect the patient to have?
104.4°F
99.2 F
100.8°F
102.2 F
The Correct Answer is A
A. 104.4°F. This temperature is consistent with heatstroke, a life-threatening condition characterized by hot, dry skin, confusion, and tachycardia. Heatstroke occurs when the body fails to regulate temperature, often exceeding 104°F (40°C).
B. 99.2°F. A temperature of 99.2°F is only slightly elevated and does not match the severe hyperthermia expected in heatstroke.
C. 100.8°F. While this temperature is above normal, it is not high enough to indicate heatstroke, which typically involves temperatures above 104°F.
D. 102.2°F. This temperature suggests heat exhaustion, a milder form of heat-related illness, but heatstroke involves higher temperatures exceeding 104°F.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Calculation:
Volume to administer = Dose ordered/ Dose available
Given:
- Ordered dose = 10 mg
- Available concentration = 10 mg/10 mL
Volume =10mg/(10mg/10mL)
= 10mL
Thus, the nurse will administer 10 mL per dose.
Correct Answer is A
Explanation
A. The nurse should review the patient's vital signs as soon as they are done. Even though vital signs can be delegated, the nurse retains accountability for assessing the data, interpreting abnormalities, and determining if further action is needed.
B. The nurse assistant should not be responsible for obtaining vital signs. Nurse assistants can take vital signs if they are properly trained and it is within their scope of practice. However, the nurse remains responsible for interpreting and acting on the results.
C. The nurse is not responsible if the nurse assistant fails to obtain the vital signs. The nurse remains accountable for delegated tasks and must ensure they are completed correctly.
D. The nurse assistant should determine if the patient's vital signs are abnormal. Nurse assistants can report abnormal findings, but they are not responsible for interpreting results or making clinical decisions—this is the nurse’s responsibility.
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