Author Question: After taking the patient's temperature, the nurse documents the value and the route used to obtain ... (Read 38 times)

Mollykgkg · **on:** Jul 22, 2018

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action?

a. Temperatures vary depending on the route used.
b. Temperatures are readings of core measurements.
c. Rectal temperatures are cooler than when taken orally.
d. Axillary temperatures are higher than oral temperatures.

Question 2

The health care provider prescription reads Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic. The patient's blood pressure is 92/66. The nurse does not give the medication.

Which action should the nurse take?
a. Documents that the medication was not given because of low blood pressure
b. Does not inform the health care provider that the medication was held
c. Does not tell the patient what the blood pressure is
d. Documents only what the blood pressure was.

morrie123456 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A
Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5 C (0.9 F) higher than oral temperatures, and axillary temperatures are usually 0.5 C (0.9 F) lower than oral temperatures. There are core temperature readings and body surface readings.

Answer to Question 2

ANS: A
The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider.