Basic Nursing Skills: Ch. 21

The nursing assistant reports to the nurse that the temperature of a patient who is first day postoperative is 100.2^oF. Which action should the nurse take first?

• Notify the surgeon of the temperature elevation

• Check the preoperative temperature reading

• Tell the nursing assistant to take the temperature again in 2 hours

• Prepare to administer an ordered PRN (as needed) acetaminophen suppository

Answer explanation

The temperature should be checked again in 2 hours, because it has been rising and is close to indicating “fever.”

Temperature greater than 105.8^oF (41^oC) should be treated promptly to reduce the fever to prevent which health risk?

• Chemical reactions to oxygen in the bloodstream

• Potential damage to the cell of the central nervous system

• Heavy perspiration causing dehydration

• The increased workload of the heart

Answer explanation

A temperature elevated this high can begin to cause cell damage, and the fever should be reduced before it reaches 106F, when cell damage is certain to occur.

Tags

NGSS.HS-LS1-3

Pulse oximetry readings should be correlated with which other assessment or findings?

• The respiratory assessment

• The vital signs

• The hemoglobin level of the blood

• Changes in blood pressure

Answer explanation

Pulse oximetry readings should correlate to other findings of respiratory assessment.

Which health condition or intervention may put a patient at risk of developing orthostatic hypotension? (Select all that apply).

• The patient has received 3 L of IV fluid within 24 hours

• The patient has diarrhea and vomiting for the past 3 days

• The patient is taking daily medications for hypertension

• The patient has been "somewhat" nauseous for 48 hours

• The patient has a sinus infection and fever with a temperature of 101.4^oF

Answer explanation

Hypotension can occur from the dehydration of vomiting and diarrhea, as well as from diuretic therapy for hypertension.

Tags

NGSS.HS-LS1-3

What are the signs and symptoms of shock that may be seen with hypotension? (Select all that apply).

• Tachypnea

• Apprehension

• Tachycardia

• Cool, clammy skin

• Increased blood pressure

Answer explanation

Apprehension, tachycardia, and cool, clammy skin are signs and symptoms of shock

When assigning vital sign measurements to the nursing assistant, the nurse says to take the apical pulse for the full 60 seconds. For which patient would this instruction be most important?

• A patient who is bradycardic

• A patient whose usual heart rate is 76 bpm

• A patient who is tachycardic

• A patient whose heart rate is irregular

Answer explanation

It would be most important for the patient with an irregular pulse.

A patient is receiving an opiate-based medication to help manage pain. Which assessment has the highest priority when monitoring the patient's condition?

• Temperature

• Pulse

• Respirations

• Blood pressure

Answer explanation

Opiate-based pain medications can suppress respirations so you must monitor respiratory rate and alert the health care provider if it is consistently low.