The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

Validate the finding

Document the finding

Inform the surgeon

Inform the charge nurse

Answer and Explanation

The Correct Answer is A

A. Validate the finding:

Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.

B. Document the finding:

Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.

C. Inform the surgeon:

If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.

D. Inform the charge nurse:

Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Wait 30 min and return to measure the oral temperature:

Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.

B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:

This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.

C. Document that the nurse was unable to measure the client’s temperature:

Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route

D. Determine if the client has eaten or drank within the last 15 minutes:

Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.

E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:

If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.

Correct Answer is ["20"]

Explanation

To administer the ordered dose of furosemide (Lasix) 20mg, you need to calculate the amount of mL required from the available solution. The available solution has a concentration of 2 mg/2 mL, which means that for every 2 mL of solution, there are 2 mg of furosemide. To find the amount of mL needed to deliver 20 mg of furosemide, you can use the following formula:

mL = (ordered dose / available dose) x available volume

Plugging in the values, we get:

mL = (20 mg / 2 mg) x 2 mL

mL = 10 x 2 mL

mL = 20 mL

Therefore, you need to administer 20 mL of the available solution to give the patient 20 mg of furosemide.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is measuring a client’s oral temperature. The thermometer reads 33 C (91.4F). Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

Ordered: furosemide (Lasix) 20mg Available: furosemide (Lasix) 2 mg/2 mL Administer: ____mL

Correct Answer is ["20"]

Explanation

A patient is having dyspnea. What would the nurse do first?

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

A nurse is assisting with the admission of an alert and oriented client to the orthopedic surgical unit. Which of the following sources of information should the nurse rely on for accurate information about the client?

A nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)