Chapter 15: Vital Signs

1.The nursing student is obtaining the patient’s vital signs. The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain?

a.
Temperature, pulse, respirations
b.
Temperature, pulse, respirations, oxygen saturation
c.
Temperature, pulse, respirations, blood pressure, oxygen saturation
d.
Temperature, pulse, respirations, blood pressure, oxygen saturation, pain

ANS: D

The cardinal vital signs are temperature, pulse, respiration, blood pressure, and oxygen saturation. A sixth vital sign, assessment of pain, is a standard of care in health care settings. Frequently pain and discomfort are the signs that lead a patient to seek health care. Therefore assessing a patient’s pain helps a nurse understand the patient’s clinical status and progress.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:270

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

2.Upon a patient’s admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurse’s responsibility regarding delegating this task?

a.
This is inappropriate delegation; the nurse should always take the vital signs.
b.
Have the NAP repeat the measurement if vital signs appear abnormal.
c.
The nurse should review and interpret the vital sign measurements.
d.
This task has been delegated so the nurse is not responsible.

ANS: C

A nurse may delegate the measurement of selected vital signs (e.g., stable patients) to nursing assistive personnel. However, it is the nurse’s responsibility to review vital sign data, interpret their significance, and critically think through decisions about interventions. When vital signs appear abnormal, repeat the measurement. When caring for a patient, the nurse is responsible for vital sign monitoring.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:271

OBJ: Correctly delegate vital sign measurement to nursing assistive personnel.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

3.A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?

a.
Call the health care provider because the patient’s values differ from the standard range.
b.
Immediately call the health care provider and request antihypertensive medication.
c.
Ask the patient what his blood pressure normally measures for comparison.
d.
Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.

ANS: C

Know the patient’s usual range of vital signs. A patient’s usual values sometimes differ from the standard range for that age or physical state. Use the patient’s usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patient’s blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:271 | 282

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

4.A nurse is working on a medical unit in an acute care hospital. One of the patients she is caring for has a fever of 100.6° F. Which of the following is the best reason why the patient should not receive an antipyretic at this time?

a.
A temperature of 100.3° F is within the normal range.
b.
Shivering is a more effective way to dissipate heat energy.
c.
Corticosteroids are safer to use than antipyretics.
d.
Mild fevers are an important defense mechanism of the body.

ANS: D

Fever, or pyrexia, is an important defense mechanism. Therefore most health care providers will not treat an adult’s fever until it is higher than 39° C (102.2° F). For healthy young adults the average oral temperature is 37° C (98.6° F). In the elderly population, the average core temperature ranges from 35° to 36.1° C (95° to 97° F) because of decreased immunity. Shivering is counterproductive because of the heat produced by muscle activity. Although not used to treat fever, corticosteroids reduce heat production by interfering with the hypothalamic response. It is important to note that these drugs mask signs of infection by suppressing the immune system.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 173 | 174 OBJ: Explain the principles and mechanisms of thermoregulation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

5.A nursing assistant asks the nurse why she needs to bathe a febrile patient. The best response is that this intervention increases heat loss through which of the following?

a.
Convection
b.
Radiation
c.
Conduction
d.
Evaporation

ANS: C

Heat loss occurs through conduction, which is the transfer of heat from one object to another with direct contact. When the warm skin touches a cooler object, heat transfers from the skin to the object until temperatures equalize. Convection is the transfer of heat away from the body by air movement. Fans promote heat loss through convection. Radiation is the transfer of heat between two objects without physical contact. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:273

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

6.A 6-year-old was taken to the hospital after having a seizure at home. The patient’s mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. The patient’s mother believes that the seizure was caused by a fever of 99.5° F, which the patient had during the course of her illness. What is the nurse’s best response?

a.
“With a temperature that high, we can only hope that there is no permanent damage.”
b.
“Fevers in this range are part of the body’s natural defense system”
c.
“Febrile seizures are common in children Nancy’s age.”
d.
“The child will need antibiotics. Does she have any allergies?”

ANS: B

Fever serves as an important defense mechanism. Therefore most health care providers will not treat an adult’s fever until it is greater than 39° C (102.2° F). A fever is usually not harmful if it stays below 39° C (102.2° F) in adults or 40° C (104° F) in children. Dehydration and febrile seizures occur during rising temperatures of children between 6 months and 3 years of age. Febrile seizures are unusual in children older than 5 years of age.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 274 | 275 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

7.A 5-year-old child was admitted for a diagnosis of meningitis with a fever of 104.5° F and nuchal rigidity. She responded to antipyretics that were ordered. In addition, the patient’s mother was asked to help reduce the fever by limiting the number of blankets covering the patient. After interventions, the child’s temperature is 100.5° F. The nurse recognized that the mother has an understanding of the patient’s condition when she states which of the following?

a.
“The high temperature is useful in fighting bacteria and viruses as long as it’s not too high.”
b.
“You need to get her temperature down quickly. She’s so uncomfortable.”
c.
“Her fever is dropping because she is shivering. She must be cold.”
d.
“She probably picked up a bacteria. That’s what kids do. That’s why they get infected.”

ANS: A

A fever is usually not harmful if it stays below 39° C (102.2° F) in adults or 40° C (104° F) in children. Increased temperature reduces the concentration of iron in the blood plasma, causing bacterial growth to slow. Fever also fights viral infections by stimulating interferon, the body’s natural virus-fighting substance. The goal is a “safe” rather than a “low” temperature. A true fever results from an alteration in the hypothalamic set point. To reach the new set point, the body produces and conserves heat. The patient experiences chills, shivers, and feels cold, even though the body temperature is rising. Most fevers in children are of viral origin, lasting only briefly, and have limited effects

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 273 | 274 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

8.The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl’s temperature rectally and obtaining a reading of 100.4° F. The mother was concerned that her daughter might be ill. Which of the following is the best response?

a.
“Children usually run lower rather than higher temperatures when ill.”
b.
“Because of her age, it is probably a bacterial infection.”
c.
“Rectal temperatures are higher than temperatures obtained orally.”
d.
“When taking multiple temperatures, the sites should be rotated.”

ANS: C

Depending on the site, temperatures will normally vary between 36° C (96.8° F) and 38° C (100.4° F). It is generally accepted that rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures. Children have immature temperature control mechanisms, so temperatures sometimes rise rapidly. Most fevers in children are of viral origin, lasting only briefly, and have limited effects. Use the same site when repeated measurements are needed.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:273 | 274 | 275

OBJ:Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

9.A 6-year-old child was taken to the after-hours pediatric clinic with a fever and a rash. She had been seen by her pediatrician earlier in the day and had been given a prescription for an antibiotic. Later that evening she developed a fever and a rash on her abdomen. The nurse who assesses the child in the clinic suspected the symptoms are associated with which of the following?

a.
Dehydration
b.
An allergic response to the prescribed medication
c.
Febrile seizures
d.
Fever of unknown origin (FUO)

ANS: B

Sometimes a fever results from a hypersensitivity response to a medication, especially when the medication is taken for the first time. These fevers are often accompanied by other allergy symptoms such as rash, hives, or itching. Treatment involves stopping the medication responsible for the reaction. Dehydration and febrile seizures occur during rising temperatures in children between 6 months and 3 years of age. Febrile seizures are unusual in children greater than 5 years of age. The term fever of unknown origin (FUO) refers to a fever whose cause cannot be determined.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 273 | 274 OBJ: Discuss physiological changes associated with fever.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

10.A 56-year-old grandmother has been admitted to the hospital with a fever of 103.2° F after caring for her 5-year-old granddaughter who also developed a fever. The health care provider has ordered blood cultures, antibiotics, antipyretics, a clear liquid diet, and a chest radiograph. Which of the orders should the nurse do first?

a.
Administer antibiotic.
b.
Administer antipyretic.
c.
Draw blood cultures.
d.
Apply water cooled blankets.

ANS: C

Before antibiotic therapy, obtain blood cultures when ordered. Obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent. Antipyretics are medications that reduce fever. It is important to note that these drugs mask signs of infection by suppressing the immune system. Physical cooling, including the use of water-cooled blankets, is appropriate when the patient’s own thermoregulation fails or in patients with neurological damage (e.g., spinal cord injury).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:274

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

11.A 26-year-old man was helping a friend replace a roof on his backyard shed after work on a hot July afternoon. His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing the patient?

a.
Place the patient in a tub of iced water.
b.
Take the patient’s temperature.
c.
Remove fans to prevent premature chilling.
d.
Apply a hyperthermia blanket to lower temperature slowly.

ANS: B

Assessment includes taking the patient’s temperature. The nurse then uses that measurement to guide care of that patient. Placing the patient in a tub of iced water, removing fans to prevent premature chilling, and applying a hyperthermia blanket to lower temperature slowly are not assessments but interventions. Prolonged exposure to the sun or high environmental temperatures overwhelms the body’s heat loss mechanisms. These conditions cause heat stroke, a dangerous heat emergency, defined as a body temperature of 40° C (104° F) or higher. Signs and symptoms of heat stroke include giddiness, confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, and even incontinence. The most important sign of heat stroke is hot, dry skin. A heat stroke can be fatal. Cool the person quickly. Ways to cool include placing wet towels over the skin, placing the person in a tub of tepid (not iced) water or into a tepid shower, spraying the person with cool water from a garden hose, and placing oscillating fans in the room. Emergency medical treatment includes applying hypothermia blankets, giving intravenous (IV) fluids, and irrigating the stomach and lower bowel with cool solutions.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:275

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

12.A 15-year-old girl was taken to a small rural hospital by her mother. The family had been camping, and it had become very cold during the night. The mother had difficulty waking her daughter in the morning, and she was shivering uncontrollably. The patient is still unconscious. Which of the following interventions should the admitting nurse do first?

a.
Have the patient drink hot liquids.
b.
Wrap the girl in warm blankets.
c.
Uncover the head to allow the head to warm.
d.
Place heating pads on the bottom of the feet.

ANS: B

The priority treatment for hypothermia is to prevent a further decrease in body temperature. Removing wet clothes, replacing them with dry ones, and wrapping the patient in blankets are strategic nursing interventions. In emergencies, when a patient is not in a health care setting, place the patient under blankets next to a warm person. A conscious patient benefits from drinking hot liquids such as soup, while avoiding alcohol and caffeinated fluids. An unconscious patient should not be given any fluids. Keeping the head covered, increasing room temperature, or placing heating pads next to areas of the body (head and neck) that lose heat the quickest helps. The severity of the hypothermia dictates the treatments performed.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:275

OBJ: Describe nursing interventions that promote heat loss and heat conservation.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

13.A senior nursing student is doing her community clinical rotation. When visiting a young family to whom she has been assigned, the mother of a 3-year-old child states that her daughter does not feel well. The nursing student feels her skin, which is warm. She asks the mother if she has taken her temperature to which the mother replies, “Yes, I used the same thermometer that was my great-grandmother’s; it has been used by my family for years. Her oral temperature was 102.3° F.” The most important action for the nursing student to perform is to do which of the following?

a.
Teach that temporal artery thermometers are more accurate than others.
b.
Tell the mother that hospitals still use mercury thermometers.
c.
Ask to see the thermometer.
d.
Recommend a chemical thermometer for greater accuracy.

ANS: C

Inspect the thermometer to make sure that it is mercury. The mercury-in-glass thermometers are obsolete in the health care setting because of the environmental hazards of mercury. However, some patients still use mercury-in-glass thermometers at home. If you find a mercury-in-glass thermometer in the home, teach the patient about safer temperature devices and encourage him or her to take the thermometer to a neighborhood hazardous disposal location. There is a growing bed of research supporting the discontinuation of temporal artery thermometers in the clinical setting because of reported inaccurate readings. Chemical thermometers are useful for screening temperatures, especially in infants and young children. You need to confirm readings with electronic thermometers when treatment decisions need to be made.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:277 | 278

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care

14.A 38-year-old postoperative patient is suddenly unresponsive but is still breathing. The nurse will use which site to assess the patient’s pulse?

a.
Apical artery
b.
Radial artery
c.
Carotid artery
d.
Brachial artery

ANS: C

When a patient’s condition suddenly deteriorates, use the carotid site to quickly locate a pulse. Assess any accessible artery for pulse rate; however, use the radial or carotid arteries most often because they are easy to locate and palpate. The radial and apical locations are the most common sites for pulse rate assessment. Use the radial or carotid pulse when teaching patients how to monitor their own heart rates. The brachial artery is not usually a primary site for checking pulse.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:279

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

15.A man has been admitted to the hospital with lethargy. He was placed on the telemetry unit and is being continuously monitored. He is due to receive his dose of digoxin. The nurse knows that the medication is to be held if the pulse rate is less than 60 beats per minute. The nurse will use which site to assess the patient’s pulse?

a.
Apical
b.
Radial
c.
Brachial
d.
Carotid

ANS: A

When a patient takes a medication that affects the heart rate, the apical pulse provides a more accurate assessment of heart rate. The radial pulse is the most common site used to assess character of pulse peripherally and assesses the status of circulation to the hand. The brachial site is used to assess upper extremity blood pressure; used during infant CPR.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:279 | 280

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

16.The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which of the following would best maximize the sound quality of what is heard through the stethoscope?

a.
Positioning the diaphragm very lightly on the area to which he is listening
b.
Placing the stethoscope chest piece directly on the patient’s skin
c.
Make sure that the earpieces fit loosely in the ear canals
d.
Use a stethoscope with the longest tubing available

ANS: B

Always place the stethoscope directly on the skin because clothing obscures the sound. Position the diaphragm to make a tight seal against the patient’s skin. Exert enough pressure on the diaphragm to leave a temporary red ring on the patient’s skin when the diaphragm is removed. Make sure the plastic or rubber earpieces fit snugly in the ear canal and that the binaurals are angled and strong enough so the earpieces stay firmly in place without causing discomfort. The polyvinyl tubing is flexible and 30 to 45 cm (12 to 18 inches) in length. Longer tubing decreases sound wave transmission.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:279

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Implementation

MSC: NCLEX: Management of Care

17.A nurse notices that a patient has an irregular pulse. The nurse should do which of the following?

a.
Count the number of “lub-dubs” occurring in 30 seconds.
b.
Assess how often the dysrhythmia is occurring.
c.
Assess the radial pulse for a pulse deficit.
d.
Chart the abnormally low heart rate as tachycardia.

ANS: B

A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm or dysrhythmia. A dysrhythmia alters cardiac function, particularly if it occurs repetitively. If your patient has a dysrhythmia you need to assess how often it is occurring. After properly positioning the bell or the diaphragm of the stethoscope on the chest, try to identify the first and second heart sounds (S1 and S2). At normal slow rates, S1 is low pitched and dull, sounding like a “lub.” S2 is a higher pitched and shorter sound and creates the sound “dub.” Count the number of “lub-dubs” occurring in 1 minute. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit, ask another nurse to assess the radial pulse rate while you assess the apical rate. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 279 | 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

18.The nurse is taking the pulse of an adult patient and finds that the patient’s heart rate is 48. He knows that this is considered:

a.
tachycardia.
b.
bradycardia.
c.
a normal heart rate for an infant.
d.
a normal heart rate for an adult.

ANS: B

Tachycardia is an abnormally elevated heart rate, greater than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults; 120 to 160 beats per minute is a normal heart rate for an infant. The normal heart rate for an adult is 60 to 100 beats per minute.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 281 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

19.A 45-year-old mother of three children is at the doctor’s office and her blood pressure 152/92. This is the first time that she has ever shown an elevated reading. She is concerned that she has hypertension. The nurse’s best response would be:

a.
“A single reading may not mean anything. We will take it again at your next visit.”
b.
“It looks like you have high blood pressure now. We’ll check it again in 3 months.”
c.
“Fortunately, hypertension isn’t related to other diseases and is easily treated.”
d.
“You may have hypertension, but there is little else that can be done except medicines.”

ANS: A

The diagnosis of hypertension in adults is made on the average of two or more readings taken at each of two or more visits after an initial screening. One blood pressure recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (for example, 150/90 mm Hg), encourage the patient to return for another checkup within 2 months. Hypertension is a known risk factor for cardiovascular morbidity and mortality. Obesity, cigarette smoking, excessive alcohol intake, elevated blood cholesterol, and continued exposure to stress are also linked to hypertension. Controlling these factors may reduce blood pressure.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

20.The patient has just returned to the postsurgical unit after undergoing surgery to remove a lung tumor. During one of the postoperative vital sign checks, the nurse notes that the patient’s systolic blood pressure had dropped by 30 points. In addition to the drop in systolic blood pressure, the patient’s skin is pale and “clammy.” The nurse should do which of the following?

a.
Report the findings to the health care provider immediately.
b.
Understand that the patient’s arteries are constricting, causing pallor.
c.
Wait to see if the blood pressure increases in 30 minutes.
d.
Nothing; this is a normal occurrence following a thoracic surgery.

ANS: A

Signs and symptoms associated with hypotension include pallor, skin mottling, clamminess, confusion, dizziness, chest pain, increased heart rate, and decreased urine output. Hypotension is usually life threatening and needs to be reported immediately to the patient’s health care provider. Doing nothing can lead to the patient’s death. Hypotension occurs when arteries dilate; the peripheral vascular resistance decreases, the circulating blood volume decreases, or the heart fails to provide adequate cardiac output.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 282 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

21.A patient is obese. At the bedside is a standard-size blood pressure cuff. The nurse realizes that the use of this cuff will provide which of the following?

a.
Accurate readings as long as it is 20% of the circumference of the midpoint of the limb.
b.
Indistinct readings if the bladder encircles 80% of the adult’s arm.
c.
A falsely low reading if the cuff is wrapped too loosely around the arm.
d.
Inaccurate readings and needs to be replaced with a larger cuff.

ANS: D

When the incorrect size cuff is used, it is possible to obtain a false reading. The size selected is proportional to the circumference of the limb being assessed. Ideally select a cuff that is 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb being used to be obtain measurements. The bladder, enclosed by the cuff, encircles at least 80% of the arm of an adult and the entire arm of a child. A cuff that is wrapped too loosely or unevenly will yield false-high readings.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 285 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

22.A woman has been hospitalized with pneumonia. She has had oxygen on via nasal cannula at a rate of 2 L per minute. A nursing student is taking her vital signs. She notes that her respirations are labored and the rate is 32 respirations per minute. The nursing student recognizes this as which of the following?

a.
Normal.
b.
Tachypnea.
c.
Bradypnea.
d.
Apnea.

ANS: B

Tachypnea is a respiratory rate greater than 20, and a rate less than 12 per minute or lower than acceptable limits is bradypnea. Apnea is the lack of respiratory movements. A normal respiratory rate for an adult is 12 to 20 breaths per minute.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF: 289 | 290 OBJ: Describe factors that cause variations in vital signs.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Management of Care

23.The patient’s temperature has reached 103.4° F. The nurse prepares to draw a blood culture before giving the patient an antipyretic medication. What is the best reason to draw a blood culture before giving an antipyretic medication?

a.
The causative organism is most prevalent during a spike in temperature.
b.
Elevated temperatures slow metabolic rate and improve blood oxygenation.
c.
Increased blood flow leads to moist mucous membranes making blood draws easier.
d.
Venous distention is greater because of fluid retention secondary to hyperthermia.

ANS: A

Obtain blood specimens at the same time as a temperature spike, when the causative organism is most prevalent. Satisfy requirements for increased metabolic rate. Provide supplemental oxygen therapy as ordered to improve oxygen delivery to body cells. Encourage oral hygiene because oral mucous membranes dry easily from dehydration and have increased potential for bacterial invasion. Replace fluids lost through insensible water loss and sweating.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:274

OBJ:Accurately assess body temperature, pulse, respiration, oxygen saturation, and blood pressure.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Management of Care