Fundamentals Exam One

• A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely?

  a.Pulse

  b. Respirations

  c. Temperature

  d. Blood pressure

  
  

  Answer: C
• A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss?

  1. Radiation
  2. Conduction
  3. Convection
  4. Evaporation

  Answer: Convection
• The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature? Conduction.
• A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take?

  a. Apply just a diaper.

  b. Double the clothing.

  c. Place a cap on their heads.

  d. Increase room temperature to 90 degrees

  
  

  Answer: c
• The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do?

  a. Call the health care provider immediately to report a possible infection.

  b. Administer medication to lower the temperature further.

  c. Provide another blanket to conserve body temperature.

  d. Realize that this is a normal temperature variation.
• The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take?

  Wait 30 minutes and recheck the patient’s temperature.

  Assume that the patient has an infection and order blood cultures.

  Encourage the patient to move around to increase muscular activity.

  Be aware that temperatures this high are harmful and affect patient safety.

  Answer: d