Question 1

Why will the nurse draw a blood culture before giving an antipyretic medication?

Accepted Answer

A)  The causative organism is most prevalent during a spike in temperature. 
B)  Elevated temperatures slow metabolic rate and improve blood oxygenation. 
C)  The antipyretic medication will inhibit bacteria growth within the culture tubes. 
D)  Venous distention is greater because of fluid retention from hyperthermia. 
A)  The causative organism is most prevalent during a spike in temperature. 
B)  Elevated temperatures slow metabolic rate and improve blood oxygenation. 
C)  The antipyretic medication will inhibit bacteria growth within the culture tubes. 
D)  Venous distention is greater because of fluid retention from hyperthermia.

Question 2

The nurse assistant is preparing to take the patient's oral temperature with a red-tipped electronic thermometer probe.What is the priority action of the nurse?

Accepted Answer

A)  Remind the nurse assistant to enter the result into the patient's medical record. 
B)  Give the nurse assistant a blue-tipped probe to take the patient's oral temperature. 
C)  Inform the patient that temperatures are most accurate when taken orally. 
D)  Direct the nurse assistant to change the thermometer probe cover daily. 
A)  Remind the nurse assistant to enter the result into the patient's medical record. 
B)  Give the nurse assistant a blue-tipped probe to take the patient's oral temperature. 
C)  Inform the patient that temperatures are most accurate when taken orally. 
D)  Direct the nurse assistant to change the thermometer probe cover daily.

Question 3

The nurse is concerned that the outside of the stethoscope is becoming dirty and unsightly.Which is the appropriate action of the nurse?

Accepted Answer

A)  Obtain a soft cloth cover for the stethoscope tubing. 
B)  Clean the stethoscope tubing throughout each shift with isopropyl alcohol. 
C)  Send the entire stethoscope to central supply for disinfection. 
D)  Clean the stethoscope tubing weekly with a solution of mild dish soap. 
A)  Obtain a soft cloth cover for the stethoscope tubing. 
B)  Clean the stethoscope tubing throughout each shift with isopropyl alcohol. 
C)  Send the entire stethoscope to central supply for disinfection. 
D)  Clean the stethoscope tubing weekly with a solution of mild dish soap.

Question 4

When getting a postoperative patient out of bed for the first time,the patient immediately feels light-headed and then faints.What are the appropriate actions of the nurse?

Accepted Answer

A)  Have the patient lie down. 
B)  Report findings to the health care provider. 
C)  Instruct the patient not to get out of bed without assistance. 
D)  Have the nursing assistant check the patient's orthostatic blood pressure. 
E)  Take the BP in each arm and use the arm with the lowest systolic reading. 
A)  Have the patient lie down. 
B)  Report findings to the health care provider. 
C)  Instruct the patient not to get out of bed without assistance. 
D)  Have the nursing assistant check the patient's orthostatic blood pressure. 
E)  Take the BP in each arm and use the arm with the lowest systolic reading.

Question 5

The nurse is caring for a patient who has just been admitted with a fever of 102.6° F.Which intervention will the nurse perform first for the patient?

Accepted Answer

A)  Administer the prescribed antibiotic. 
B)  Administer the prescribed antipyretic. 
C)  Draw blood cultures for laboratory testing. 
D)  Apply a cool washcloth to the patient's forehead. 
A)  Administer the prescribed antibiotic. 
B)  Administer the prescribed antipyretic. 
C)  Draw blood cultures for laboratory testing. 
D)  Apply a cool washcloth to the patient's forehead.

Question 6

The nurse is caring for a patient who suffered a traumatic head injury.The patient's temperature rises to 104.5° F but there is no evidence of infection.Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever?

Accepted Answer

A)  "The area of the brain that controls body temperature was damaged." 
B)  "The body is compensating for losing too much body heat in the accident." 
C)  "I will contact the physician now to obtain an order for antibiotics." 
D)  "The hospital room must be too warm so I will turn down the thermostat." 
A)  "The area of the brain that controls body temperature was damaged." 
B)  "The body is compensating for losing too much body heat in the accident." 
C)  "I will contact the physician now to obtain an order for antibiotics." 
D)  "The hospital room must be too warm so I will turn down the thermostat."

Question 7

The nurse is caring for a patient who collapsed after working outside on a hot day.The patient is disoriented with hot,dry skin and heart rate of 140 beats/minute.Which temperature will the nurse expect the patient to have?

Accepted Answer

A)  99.2° F 
B)  100.8° F 
C)  102.2° F 
D)  104.4° F 
A)  99.2° F 
B)  100.8° F 
C)  102.2° F 
D)  104.4° F

Question 8

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?

Accepted Answer

A)  The patient is exhausted from shivering. 
B)  The patient's infection has spread to the bloodstream. 
C)  Vasodilation is working to lower the body temperature. 
D)  The patient's core temperature has dropped too low. 
A)  The patient is exhausted from shivering. 
B)  The patient's infection has spread to the bloodstream. 
C)  Vasodilation is working to lower the body temperature. 
D)  The patient's core temperature has dropped too low.

Question 9

The nurse is caring for an unconscious,intubated patient in the intensive care unit.Which methods may be used to check the patient's temperature?

Accepted Answer

A)  Axillary 
B)  Rectal 
C)  Oral 
D)  Tympanic 
E)  Pulmonary artery 
A)  Axillary 
B)  Rectal 
C)  Oral 
D)  Tympanic 
E)  Pulmonary artery

Question 10

The nurse applies a warmed blanket to a chilled patient.Which term is used to describe the process by which the blanket increases the patient's temperature?

Accepted Answer

A)  Convection 
B)  Radiation 
C)  Conduction 
D)  Emission 
A)  Convection 
B)  Radiation 
C)  Conduction 
D)  Emission

Exam 15: Vital Signs

Why will the nurse draw a blood culture before giving an antipyretic medication?

The nurse assistant is preparing to take the patient's oral temperature with a red-tipped electronic thermometer probe.What is the priority action of the nurse?

The nurse is concerned that the outside of the stethoscope is becoming dirty and unsightly.Which is the appropriate action of the nurse?

When getting a postoperative patient out of bed for the first time,the patient immediately feels light-headed and then faints.What are the appropriate actions of the nurse?

The nurse is caring for a patient who has just been admitted with a fever of 102.6° F.Which intervention will the nurse perform first for the patient?

The nurse is caring for a patient who suffered a traumatic head injury.The patient's temperature rises to 104.5° F but there is no evidence of infection.Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever?

The nurse is caring for a patient who collapsed after working outside on a hot day.The patient is disoriented with hot,dry skin and heart rate of 140 beats/minute.Which temperature will the nurse expect the patient to have?

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 nurse is caring for an unconscious,intubated patient in the intensive care unit.Which methods may be used to check the patient's temperature?

The nurse applies a warmed blanket to a chilled patient.Which term is used to describe the process by which the blanket increases the patient's temperature?

Professional Nursing

Health and Wellness

The Health Care Delivery System

Community-Based Nursing Practice

Legal Principles in Nursing

Ethics

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Critical Thinking

Nursing Process

Informatics and Documentation

Communication

Patient Education

Managing Patient Care

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Health Assessment and Physical Examination

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