You have delegated vital signs to the assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to
Walt 30 minutes and take an oral temperature
Advise the patient to drink a glass of cold water
Take a rectal temperature
Take the oral temperature as planned
The Correct Answer is A
A. Wait 30 minutes and take an oral temperature. Waiting 30 minutes ensures an accurate reading, as consuming hot or cold foods or drinks can alter oral temperature results.
B. Advise the patient to drink a glass of cold water. Drinking cold water could artificially lower the oral temperature, leading to an inaccurate measurement.
C. Take a rectal temperature. A rectal temperature is not necessary in this situation unless a core temperature is required for clinical reasons.
D. Take the oral temperature as planned. Taking the oral temperature immediately after hot soup can result in a falsely elevated reading, making it unreliable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Remove fans to prevent premature chilling. While preventing rapid cooling is important in some cases, this action is not the priority. The patient’s symptoms suggest heat-related illness, which requires immediate assessment.
B. Apply a hyperthermia blanket to lower temperature slowly. Hyperthermia blankets are typically used in controlled environments for gradual cooling, but first, the patient’s temperature must be assessed to determine the severity of heat-related illness.
C. Take the patient's temperature and vital signs. Confusion and muscle cramps after working in heat suggest possible heat exhaustion or heatstroke, which can be life-threatening. Assessing temperature and vital signs is the priority to determine the severity and guide further treatment.
D. Place the patient in a tub of iced water. Ice water immersion is appropriate for severe heatstroke with a dangerously high core temperature, but cooling measures should only be initiated after confirming hyperthermia with a temperature assessment.
Correct Answer is D
Explanation
A. Perception occurs when the brain interprets pain signals and recognizes them as pain. This step happens after the nerve impulses have been transmitted to the brain.
B. Transduction is the first step in the pain process, where painful stimuli (such as cutting a finger) activate nociceptors, converting the stimulus into an electrical signal.
C. Modulation involves the body’s response to pain signals, where descending nerve pathways release substances like endorphins to inhibit pain transmission. This occurs later in the pain process.
D. Transmission is the process of pain signals traveling from the site of injury to the spinal cord and brain via afferent nerve fibers. This step occurs after transduction and allows pain signals to reach the central nervous system.
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