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 A
Explanation
Localized warmth is a classic sign of inflammation and can indicate the presence of an infection or injury in the affected area. Sanguineous drainage is a type of wound drainage that consists of blood and is not a sign of inflammation. Palpable pedal pulses and full range of motion can provide information about the injury, but they are not specific to inflammation. Therefore, options b, c, and d are incorrect.
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