A nurse is assessing a client who has an oral temperature of 39 degrees Celsius. Which of the following findings should the nurse expect?

Decreased peripheral pulses

Respiratory rate 10/min

Heart rate 108/min

Dilated pupils

Answer and Explanation

The Correct Answer is C

The nurse should expect to find an increased heart rate in a client with a fever. An elevated body temperature can cause an increase in metabolic rate, which can lead to an increase in heart rate. This is a normal physiological response to fever and helps the body to generate heat and fight oﬀ infection.

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Correct Answer is A

Explanation

Postural hypotension, also known as orthostatic hypotension, is a form of low blood pressure that occurs when standing up from a sitting or lying down position 1. An eﬀective intervention for postural hypotension would be one that helps to prevent a significant drop in blood pressure when the client changes position. A small decrease in systolic blood pressure, such as from 110 mm Hg to 105 mm Hg, would indicate that the intervention is eﬀective in preventing a larger drop in blood pressure.

A. Opens the first ﬂap of the sterile package towards the nurse’s body. B. Prepares the sterile field 2 hours before it is needed. C. Inspects the sterile package for holes before opening. D. Places the sterile field against a wall in the client’s room.

Correct Answer is C

Explanation

When setting up a sterile field, it is important to inspect the sterile package for holes before opening it to ensure that the contents are still sterile1. The first ﬂap of the package should be opened away from the body

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A nurse is assessing a client who has an oral temperature of 39 degrees Celsius. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is eﬀective?

Correct Answer is A

Explanation

A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Correct Answer is C

Explanation

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