Author Question: The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that ... (Read 77 times)

brutforce · **on:** Jul 22, 2018

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

a. Call the physician immediately to report a possible infection.
b. Realize that this is a normal temperature variation.
c. Provide another blanket to conserve body temperature.
d. Provide medication to lower the temperature further.

Question 2

The nurse is providing diabetic diet teaching to a Hispanic man and his wife.

When the nurse is discussing foods that are acceptable, the wife continues to interrupt with statements like, Oh, he doesn't eat that, or, All he eats is rice and beans. What should the nurse do? a. Ask the wife to leave so he/she can focus on teaching the patient.
b. Explain how rice and beans are not acceptable foods on a diabetic diet.
c. Provide a diet plan with only food alternatives selected by the patient.
d. Refer the patient and his wife to a dietitian familiar with Spanish food choices.

asdfghjkl; · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Body temperature normally changes 0.5 C to 1 C (0.9 F to 1.8 F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, making this variation normal for the time of day. Unless the patient is complaining of being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a physician to report a normal temperature variation.

Answer to Question 2

D
The nurse should refer the patient to speak with a dietitian who is familiar with cultural food choices. If possible, he/she should develop a diet plan that includes the patient's cultural diet preferences and can provide culturally sensitive teaching brochures that describe healthy food choices. Rice and beans may be acceptable alternatives in a balanced diet. The nurse should include people in the family who help shop for and prepare food in the home, along with the wife.