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 C
Explanation
Choice A reason: This is an incorrect choice because sleep-wake pattern is not the most important assessment to determine if a patient is receiving sufficient sleep. Sleep-wake pattern is the cycle of sleeping and waking that follows a circadian rhythm. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep-wake patterns that suit their needs and preferences.
Choice B reason: This is an incorrect choice because hours of sleep each night is not the most important assessment to determine if a patient is receiving sufficient sleep. Hours of sleep each night is the duration of sleep that a person gets in a 24-hour period. However, it is not a reliable indicator of sleep quality or quantity, as different people may have different sleep needs and requirements that vary according to age, lifestyle, health, and other factors.
Choice C reason: This is the correct choice because whether the patient feels rested is the most important assessment to determine if a patient is receiving sufficient sleep. Feeling rested is the subjective perception of the patient about their sleep quality and quantity. It is a reliable indicator of sleep sufficiency, as it reflects the patient's satisfaction and well-being after sleeping.
Choice D reason: This is an incorrect choice because frequency of nocturia is not the most important assessment to determine if a patient is receiving sufficient sleep. Frequency of nocturia is the number of times that a person has to urinate at night. However, it is not a reliable indicator of sleep quality or quantity, as it may be influenced by other factors such as fluid intake, medication, or medical conditions.
Correct Answer is D
Explanation
Choice A reason: This is incorrect. Wiping up the liquid with paper towels and gloves can spread the mercury droplets and increase the risk of exposure. Mercury can also penetrate through nitrile gloves and cause skin irritation.
Choice B reason: This is incorrect. Disinfecting the area with chlorine bleach can create toxic vapours that can harm the respiratory system. Chlorine bleach is not effective in removing mercury from the surface.
Choice C reason: This is incorrect. Contacting the housekeeping staff to mop up the liquid can delay the proper clean-up and disposal of mercury. Mopping can also disperse the mercury droplets and contaminate the mop and the water.
Choice D reason: This is correct. Consulting the agency’s materials safety data sheets (MSDS) is the priority action of the nurse. MSDS provide information on the hazards, precautions, and procedures for handling and disposing of mercury. The nurse should follow the MSDS guidelines and use the appropriate equipment and methods to clean up the spill.
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