The nurse is caring for a patient whose temperature has dropped from 102.4°F to 99.4°F. The nurse notes that the patient’s face is flushed. What is the reason for this assessment finding?
The patient’s core temperature has dropped too low.
Vasodilation is working to lower the body temperature.
The patient is exhausted from shivering.
The patient’s infection has spread to the bloodstream.
The Correct Answer is B
Choice A reason: This is an incorrect choice because the patient’s core temperature has not dropped too low. The normal body temperature range is 97.7°F to 99.5°F¹. The patient’s temperature is still within this range, although it has decreased from a feverish level.
Choice B reason: This is the correct choice because vasodilation is the process of widening the blood vessels to increase blood flow and heat loss². This is a natural response of the body to lower the temperature when it is too high. Vasodilation can cause the skin to appear flushed and feel warm to the touch³.
Choice C reason: This is an incorrect choice because the patient is not exhausted from shivering. Shivering is another mechanism of the body to increase the temperature when it is too low². Shivering involves involuntary muscle contractions that generate heat³. The patient’s temperature is not too low, so shivering is not likely to occur.
Choice D reason: This is an incorrect choice because the patient’s infection has not spread to the bloodstream. A bloodstream infection, or sepsis, is a serious condition that can cause a high fever, not a low one. Sepsis can also cause other symptoms, such as chills, rapid breathing, and confusion. The patient’s temperature has dropped, not increased, and there is no evidence of sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because soaking the crusted areas of tape with adhesive remover is not the best approach to change nasogastric tube tape that has become crusted with secretions. Adhesive remover is a solvent that can dissolve the glue that holds the tape to the skin. However, it can also irritate the skin and cause redness, burning, or allergic reactions. The nurse should avoid using adhesive remover on the patient's face, especially near the eyes, nose, or mouth.
Choice B reason: This is an incorrect choice because saturating the tape with a denatured alcohol solution is not the best approach to change nasogastric tube tape that has become crusted with secretions. Denatured alcohol is a mixture of ethanol and other chemicals that can dissolve the glue that holds the tape to the skin. However, it can also dry out the skin and cause cracking, peeling, or bleeding. The nurse should avoid using denatured alcohol on the patient's face, especially near the eyes, nose, or mouth.
Choice C reason: This is an incorrect choice because using blunt-edged scissors to loosen the tape from the skin is not the best approach to change nasogastric tube tape that has become crusted with secretions. Blunt-edged scissors are scissors that have rounded tips instead of sharp points. They can be used to cut the tape without injuring the skin. However, they can also pull or tug on the skin and cause pain, discomfort, or damage. The nurse should avoid using scissors on the patient's face, especially near the eyes, nose, or mouth.
Choice D reason: This is the correct choice because softening the secretions using a warm moist washcloth is the best approach to change nasogastric tube tape that has become crusted with secretions. A warm moist washcloth is a cloth that is soaked in warm water and wrung out. It can be applied gently to the crusted areas of tape to soften the secretions and loosen the tape from the skin. It can also soothe the skin and prevent irritation or infection. The nurse should use a clean washcloth for each application and discard it after use.
Correct Answer is B
Explanation
Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.
Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.
Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 8 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.
Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.
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