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 the hospice RN works closely with the patient’s daughter to ensure that the patient’s dying requests are met is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Working closely with the patient’s daughter is an example of family-centered care, not team nursing.
Choice B reason: This is an incorrect choice because the RN cares for the same five patients every day during their stay following joint replacement surgery is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Caring for the same five patients every day is an example of primary nursing, not team nursing.
Choice C reason: This is the correct choice because the RN, the LPN, and the nursing assistant work together to provide all the care needed by eight patients for the shift is a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Each member of the team performs specific duties appropriate to their role to provide total patient care. Teams may include licensed practical nurses (LPNs) and unlicensed assistive personnel (UAP) that are supervised by a registered nurse (RN). Less experienced, or non-critical care RNs, may be assigned to a team in a critical care unit led by an experienced critical care RN. Each team member plays a vital role.
Choice D reason: This is an incorrect choice because the RN coordinates care of the patient with the physician assistant to ensure that the clinical pathway is followed is not a patient assignment that demonstrates the concept of team nursing. Team nursing is a model of care in which a team of healthcare providers, including RNs, licensed practical nurses (LPNs), nursing assistants, and other support staff, work together to provide care for a group of patients¹. Coordinating care of the patient with the physician assistant is an example of interprofessional collaboration, not team nursing.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: This is incorrect. The patient takes 30 mg morphine sulfate daily does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Morphine sulfate is an opioid analgesic that can be used in combination with ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), for moderate to severe pain. The nurse should monitor the patient for signs of respiratory depression, sedation, or constipation, but there is no need to clarify the order.
Choice B reason: This is incorrect. The patient has severe joint pain due to aggressive arthritis does not lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen is indicated for the relief of signs and symptoms of rheumatoid arthritis and osteoarthritis. The nurse should assess the patient's pain level, response to treatment, and adverse effects, but there is no need to clarify the order.
Choice C reason: This is correct. The patient has a gastrointestinal bleed leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause gastrointestinal irritation, ulceration, bleeding, and perforation. The nurse should question the order and consider alternative analgesics for the patient, especially if they have a history of peptic ulcer disease, gastritis, or bleeding disorders.
Choice D reason: This is correct. The patient has a history of diabetes and early renal failure leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can impair renal function, increase blood pressure, and interfere with the effects of antihypertensive and antidiabetic drugs. The nurse should question the order and monitor the patient's renal function, blood pressure, and blood glucose levels closely.
Choice E reason: This is correct. The patient has allergies to shellfish, strawberries, and iodine leads the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours. Ibuprofen can cause hypersensitivity reactions, such as rash, angioedema, bronchospasm, or anaphylaxis. The nurse should question the order and ask the patient about any previous reactions to NSAIDs or aspirin. The patient may need to avoid ibuprofen and use a different analgesic..
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