You have delegated vital signs to the assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to
Walt 30 minutes and take an oral temperature
Advise the patient to drink a glass of cold water
Take a rectal temperature
Take the oral temperature as planned
The Correct Answer is A
A. Wait 30 minutes and take an oral temperature. Waiting 30 minutes ensures an accurate reading, as consuming hot or cold foods or drinks can alter oral temperature results.
B. Advise the patient to drink a glass of cold water. Drinking cold water could artificially lower the oral temperature, leading to an inaccurate measurement.
C. Take a rectal temperature. A rectal temperature is not necessary in this situation unless a core temperature is required for clinical reasons.
D. Take the oral temperature as planned. Taking the oral temperature immediately after hot soup can result in a falsely elevated reading, making it unreliable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Due to a specific stimulus. Pain can occur with or without an identifiable stimulus. Conditions like neuropathic pain or phantom limb pain exist without an obvious external cause.
B. Caused by a single physiological situation. Pain can result from multiple factors, including tissue damage, nerve dysfunction, inflammation, and psychological influences. It is not limited to one specific physiological cause.
C. Universally the same for everyone. Pain perception varies widely between individuals due to differences in pain tolerance, cultural background, past experiences, and psychological state.
D. Subjective. Pain is defined as whatever the patient says it is, making it a subjective experience. It cannot be measured objectively, and the best indicator of pain is the patient’s self-report.
Correct Answer is B
Explanation
A. Check the patient's apical rate to check for a pulse deficit. While an apical pulse assessment may be useful later, the priority in a sudden drop in blood pressure with signs of fainting is to ensure adequate circulation by checking a central pulse.
B. Immediately check the client's carotid pulse. A significant blood pressure drop (132/82 to 104/52), pale skin, and signs of fainting suggest possible shock or circulatory collapse. The carotid pulse should be checked immediately to assess perfusion.
C. Elevate the head of the patient's bed to at least 45 degrees. Raising the head of the bed could worsen hypotension and decrease blood flow to the brain, increasing the risk of syncope. The Trendelenburg position or lying flat may be more appropriate.
D. Report the findings to the health care provider immediately. While the provider should be notified, the priority action is to assess circulation by checking the carotid pulse first before escalating care.
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