Author Question: The hand-off report nurse states to the student nurse that the client was febrile during the night. ... (Read 94 times)

Charlie · **on:** Jul 17, 2018

The hand-off report nurse states to the student nurse that the client was febrile during the night. Based on this information, what is considered a fever by the oral route?

A) 35.5C37.5C (95.9F99.5F)
B) 36.6C38C (97.9F100.4F)
C) 34.7C37.3C (94.5F99.1F)
D) 37.5C39.4C (100F103F)

Question 2

A 25-year-old client is admitted to a healthcare facility with complaints of fever, vomiting, and watery diarrhea for 2 days. On examination, the client has dry skin, delayed skin turgor, and hypotension. What is the most likely nursing diagnosis?

A) Impaired urinary elimination
B) Acute gastroenteritis
C) Infective diarrhea
D) Deficient fluid volume

lolol · **Reply #1 on:** Jul 17, 2018

Answer to Question 1

D
Feedback:
Oral temperatures in fever can range from 37.5C to 39.4C (100F103 F) or greater. Normal temperatures by route are as follows: Oral: 35.5C37.5C (95.9F99.5F); Rectal: 36.6C38C (97.9F100.4F); Axillary: 34.7C37.3C (94.5F99.1F).

Answer to Question 2

D
Feedback:
Deficient fluid volume related to vomiting and diarrhea as evidenced by hypotension, dry mouth, dry skin, and delayed skin turgor is the most likely nursing diagnosis. Impaired urinary elimination is a nursing diagnosis only if there is a change in urine volume, which is not mentioned in this case. Acute gastroenteritis and infective diarrhea are not nursing diagnoses.