The nurse is caring for a patient whose temperature has dropped from 102.4°F to 99.4°F. The nurse notes that the patient’s face is flushed. What is the reason for this assessment finding?

The patient’s core temperature has dropped too low.

Vasodilation is working to lower the body temperature.

The patient is exhausted from shivering.

The patient’s infection has spread to the bloodstream.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an incorrect choice because the patient’s core temperature has not dropped too low. The normal body temperature range is 97.7°F to 99.5°F¹. The patient’s temperature is still within this range, although it has decreased from a feverish level.

Choice B reason: This is the correct choice because vasodilation is the process of widening the blood vessels to increase blood flow and heat loss². This is a natural response of the body to lower the temperature when it is too high. Vasodilation can cause the skin to appear flushed and feel warm to the touch³.

Choice C reason: This is an incorrect choice because the patient is not exhausted from shivering. Shivering is another mechanism of the body to increase the temperature when it is too low². Shivering involves involuntary muscle contractions that generate heat³. The patient’s temperature is not too low, so shivering is not likely to occur.

Choice D reason: This is an incorrect choice because the patient’s infection has not spread to the bloodstream. A bloodstream infection, or sepsis, is a serious condition that can cause a high fever, not a low one. Sepsis can also cause other symptoms, such as chills, rapid breathing, and confusion. The patient’s temperature has dropped, not increased, and there is no evidence of sepsis.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

Choice A reason: This is correct. Taking metoprolol to treat hypertension can put the patient at high risk for development of vision problems. Metoprolol is a beta-blocker medication that can lower the blood pressure and heart rate. It can also reduce the blood flow to the eyes and cause dry eyes, blurred vision, or eye irritation.

Choice B reason: This is incorrect. Taking docusate sodium for constipation does not put the patient at high risk for development of vision problems. Docusate sodium is a stool softener medication that can ease the passage of hard stools. It does not have any direct effect on the eyes or vision.

Choice C reason: This is incorrect. Taking acetaminophen for osteoarthritis pain does not put the patient at high risk for development of vision problems. Acetaminophen is a pain reliever medication that can reduce inflammation and fever. It does not have any significant impact on the eyes or vision.

Choice D reason: This is correct. Taking insulin glulisine for type 1 diabetes can put the patient at high risk for development of vision problems. Insulin glulisine is a fast-acting insulin medication that can lower the blood sugar level. It can also cause fluctuations in the fluid balance and pressure in the eyes, leading to blurred vision, cataracts, glaucoma, or diabetic retinopathy.

Choice E reason: This is correct. Taking prednisone for multiple sclerosis can put the patient at high risk for development of vision problems. Prednisone is a corticosteroid medication that can suppress the immune system and reduce inflammation. It can also increase the intraocular pressure and cause cataracts, glaucoma, or optic nerve damage.

A. Temperature, pulse, blood pressure B. Pulse, respirations, oxygen saturation C. Temperature, pulse, respirations D. Respirations, blood pressure, pain

Correct Answer is B

Explanation

Choice A reason: This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.

Choice B reason: This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.

Choice C reason: This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.

Choice D reason: This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.

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The nurse is caring for a patient whose temperature has dropped from 102.4°F to 99.4°F. The nurse notes that the patient’s face is flushed. What is the reason for this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment findings put the patient at high risk for development of vision problems? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

Which vital signs are most important for a patient who is experiencing shortness of breath?

Correct Answer is B

Explanation

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