Ch. 67 Themroregulation Flashcards
A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.)
A. Obtain culture specimens before initiating antimicrobials.
B. Restrict the client’s oral fluid intake.
C. Encourage the client to rest and limit activity.
D. Allow the client to shiver to dispel excess heat.
E. Assist the client with oral hygiene frequently.
A. CORRECT: The provider can prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain culture specimens before initiating antimicrobial therapy to prevent interference
with the detection of the infection.
C. CORRECT: Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production.
E. CORRECT: Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips.
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?
A. “Do not measure the client’s temperature rectally.”
B. “Count the client’s radial pulse for 30 seconds and multiply it by 2.”
C. “Do not let the client know you are counting their respirations.”
D. “Let the client rest for 5 minutes before you measure their blood pressure.”
A. CORRECT: The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client.
A nurse is instructing a group of assistive
personnel in measuring a client’s respiratory
rate. Which of the following guidelines should the nurse include? (Select all that apply.)
A. Place the client in semi‑Fowler’s position.
B. Have the client rest an arm across the abdomen.
C. Observe one full respiratory cycle before counting the rate.
D. Count the rate for 30 sec if it is irregular.
E. Count and report any sighs the client demonstrates
A. CORRECT: Having the client sit upright facilitates full ventilation and gives the assistive personnel a clear view of chest and abdominal movements.
B. CORRECT: With the client’s arm across the abdomen or lower chest, it is easier for the AP to see respiratory movements.
C. CORRECT: Observing for one full respiratory cycle before starting to count assists the AP in obtaining an accurate count.
A nurse is measuring the blood pressure of a
client who has a fractured femur. The blood
pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first?
A. Request a prescription for an antihypertensive medication.
B. Ask the client if they are having pain.
C. Request a prescription for an antianxiety medication.
D. Return in 30 min to recheck the client’s blood pressure.
B. CORRECT: The first action that should be taken using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood
pressure. Therefore, the priority is to perform a pain assessment. If the client’s blood pressure is still elevated after pain interventions, report this finding to the provider.
A nurse is performing an admission assessment on a client. The nurse determines the client’s radial pulse
rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client’s pulse deficit?
16/min
The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84‑68 = 16
A nurse administered midazolam IV bolus
to a client before a procedure. The client’s
blood pressure is 86/40 mm Hg, and the heart rate is 134/min. Which of the following IV medications should the nurse administer?
A. Naloxone
B. Morphine
C. Flumazenil
D. Atropine
C. CORRECT: Midazolam is a benzodiazepine.
Administer flumazenil to reverse its effects.
A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action?
A. Assess oxygen saturation.
B. Measure blood pressure.
C. Palpate pulse rate.
D. Check temperature.
A. CORRECT: The greatest risk for the client is injury from hypoxia. Therefore, this is the priority finding.
A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? (Select all that apply.)
A. Infuse iced IV fluids.
B. Provide 100% oxygen.
C. Place a cooling blanket on the client.
D. Treat the complication while the surgeon continues surgery.
E. Administer IV dantrolene.
A. CORRECT: Infusing iced IV fluids should help lower the client’s rapidly rising temperature.
B. CORRECT: Providing 100% oxygen will help
prevent hypoxia due to muscle tremors and
rigidity from increased lactic acid.
C. CORRECT: Placing a cooling blanket on the client will help lower the rapidly rising temperature.
E. CORRECT: Dantrolene IV is a muscle relaxant that treats malignant hyperthermia.
A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take?
A. Monitor blood creatinine levels.
B. Provide airway support.
C. Turn the client to the right side.
D. Administer a diuretic.
B. CORRECT: A systemic toxic reaction results in CNS depression. In this event, it is important to support the client’s airway with maintaining patency and administering supplemental oxygen.
A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take?
A. Decrease the client’s fluid intake.
B. Apply pressure to the puncture site.
C. Place the head of the bed flat.
D. Instruct the client to lie prone.
C. CORRECT: Placing the head of the bed flat will decrease the intensity of the headache.
