Watch and Learn Flashcards
A patient has a temperature of 106°F (41°C). What does this mean?
This is a medical emergency.
Rationale:
A fever of 106°F (41°C) is a medical emergency and needs to be addressed immediately. Within 24 hours is too delayed, they need intervention, and a fever that high does not indicate recovery.
What temperature would be considered a fever in an adult?
100.2°F (37.9°C)
Rationale:
A temperature over 99.5°F (37.5°C) is considered a fever in an adult.
Which is a preferred nonpharmacologic method to treat a fever?
Cooling blankets
Rationale:
Cooling blankets, ice packs, and cool sponge baths can assist in lowering a temperature. Heat is not recommended.
What is true of older adults and fevers?
Older adults are less likely to spike a fever, even with a serious infection.
Rationale:
Older adults are less likely to spike a fever due to lower baseline body temperatures. They do not have different symptoms or spike lower fevers.
Which medication is used to treat the symptoms of a fever?
Acetaminophen
Rationale:
Acetaminophen is an antipyretic used to lower fevers and help manage symptoms. Diphenhydramine is an antihistamine. Guaifenesin is an expectorant, and amoxicillin is an antibiotic. Antibiotics may be used to treat the infection causing the fever, but it will not treat the fever symptoms.
Which blood pressure reading is considered hypotensive?
86/42 mm Hg
Rationale:
86/42 mm Hg is the lowest of these readings and considered hypotensive. Any blood pressure below 90/60 mm Hg is considered hypotensive.
Which is a symptom of hypotension?
Dizziness
Rationale:
Dizziness from not getting enough blood to the brain is a symptom of low blood pressure. Increased energy, polyuria, and dilated pupils are not symptoms associated with hypotension.
A patient has a baseline blood pressure of 86/42 mm Hg and is resting comfortably in their room talking on their phone. Their current blood pressure is 84/42 mm Hg. What is the nurse’s best course of action?
Continue to monitor the patient.
Rationale:
This patient is comfortable, not in distress, and has a blood pressure consistent with their baseline. Although this patient is hypotensive, they are stable, and the most appropriate action is continuing to monitor them.
Which is not a cause of hypotension?
Activation of the sympathetic nervous system
Rationale:
Activating the sympathetic nervous system would increase blood pressure and heart rate rather than decreasing blood pressure. A vagal response, shock, and hypovolemia would all cause low blood pressure.
What is the first intervention when working with a patient who is hypotensive?
Ensure the patient is safe.
Rationale:
Ensuring safety is the first priority since hypotension can put a patient at risk for falls. The nurse should make sure the patient is lying down and out of harm’s way before proceeding with other interventions.
