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 C

Explanation

A high white blood cell (WBC) count usually indicates an increase in the production of white blood cells to fight an infection

A. A client who has haemorrhoids B. A client who had recent oral surgery C. A client who has a coagulation disorder D. A client who is drinking ice water

Correct Answer is A

Explanation

Answer: A

Rationale:

A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.

B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.

C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.

D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.

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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?

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Naxlex Comprehensive Predictor Exams

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