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. 40-year-old with a pulse of 88. A resting pulse of 88 beats per minute is within the normal adult range (60–100 bpm) and does not require further assessment.
B. 18-year-old with a pulse rate of 140 after riding 2 miles on an exercise bike. An increased heart rate after exercise is a normal physiological response, and the heart rate should return to baseline after rest. No further assessment is needed unless tachycardia persists.
C. 50-year-old man with a BP of 112/60 mmHg on awakening in the morning. This blood pressure is within a normal range, especially in the early morning when BP is often lower. No additional assessment is required.
D. 65-year-old with a respiratory rate of 10/min. A normal respiratory rate for an adult is 12–20 breaths per minute. A respiratory rate of 10 is lower than normal and may indicate respiratory depression, which could be caused by medications such as opioids, neurological issues, or other conditions requiring further evaluation.
Correct Answer is B
Explanation
A. Perception. Perception occurs when the brain processes and interprets the pain signal, which happens after the stimulus has been converted and transmitted.
B. Transduction. Transduction is the process where a painful stimulus, such as touching a hot stove, causes cellular damage, leading to the release of chemical mediators that convert the stimulus into a pain impulse.
C. Modulation. Modulation involves the body's response to pain, including the release of endorphins to inhibit pain signals and reduce pain sensation.
D. Transmission. Transmission refers to the movement of the pain impulse from the site of injury to the spinal cord and brain, occurring after transduction has taken place.
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