The nurse is working at a local fair on a warm day in August. ...

[joe]

The nurse is working at a local fair on a warm day in August. Which reading would concern the nurse the most?
 
  1. 22-year-old man with temperature of 100.2 F oral
  2. 74-year-old woman with temperature of 100.8 F oral
  3. Newborn temperature of 99.6 F axillary
  4. Middle-aged adult with temperature of 99.2 F oral

Question 2

The nurse is caring for a homeless client brought to the emergency department with possible hypothermia. The nurse places the pulse oximeter probe on the client's finger and gets a reading of 38.
 
  The client's respiratory rate is 22 breaths per minute, breath sounds are clear and equal, color is pale pink, and the client denies any history of respiratory distress. Which is the priority action by the nurse?
  1. Apply oxygen
  2. Call the health care provider
  3. Call the rapid response team
  4. Move the pulse oximetry sensor to the ear or nose

[bubulittle310@msn.cn]

Answer to Question 1

Correct Answer: 2

Older adult clients do not have efficient temperature regulatory systems, placing them at increased risk for hypothermia and hyperthermia. On a warm day, an older adult client with a temperature of 100.8 F would be a concern to the nurse, who would attempt to cool the client and encourage fluid intake. It is not unusual for the other adult clients to have a mildly elevated temperature on a warm day. Newborns' temperatures are highly dependent on environmental temperature and how they are dressed, so the infant should be undressed and allowed to cool, and then temperature should be reassessed.

Answer to Question 2

Correct Answer: 4

The nurse should move the sensor to a central area, such as the ear or nose, because the client who was exposed to the cold most likely has diminished peripheral perfusion, which could give a falsely low oximetry reading. The client's assessment does not indicate respiratory distress, so application of oxygen or calling the health care provider would not be warranted at this time. The rapid response team usually is not required in the emergency department because there are health care providers available.