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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When performing perineal care for a female client, the nurse should use soap and water to clean the client’s perineum. This helps to remove any urine or fecal mater and prevent skin irritation or infection. The nurse should also use a clean section of the washcloth for each area cleaned and should clean from front to back to prevent the spread of bacteria from the rectal area to the urethra.
Correct Answer is C
Explanation
Supplemental oxygen is administered to increase the amount of oxygen in the body and improve tissue oxygenation. The goal of this intervention is to improve the client's condition and reduce symptoms of hypoxia.
Options a, b, and d are all indicative of ongoing hypoxia and are not desirable outcomes. An increase in heart rate and respiratory rate and restlessness can be a sign that the client is still struggling to breathe and not getting enough oxygen.
Option c, pink mucous membranes, is indicative of improved tissue oxygenation. The mucous membranes, such as those in the mouth and nose, should be a healthy pink color when oxygen levels are adequate. Therefore, the nurse should identify pink mucous membranes as an indication that the intervention was effective in improving the client's hypoxia.
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