Answer to Question 1
ANS: A
Tachycardia (rapid heart rate) is often caused by factors such as pain, anxiety, fever, or fluid volume alterations. The nurse should assess the patient thoroughly for possible causative factors. Since the pulse is regular, there is no reason to take an apical pulse. The findings should be documented, but the nurse needs to do more. The provider may or may not need to be notified, depending on the outcome of the nurse's assessment.
Answer to Question 2
ANS: B
Oral temperatures will be inaccurate if the patient has been drinking or eating hot or cold foods. The nurse instructs the patient not to continue drinking the coffee and returns in 30 minutes to take the temperature. Drinking room temperature water will not even out the patient's mouth temperature. The rectal route is not preferred by patients and should not be used in this situation. The nurse needs a temperature and so should not document that it was not obtained.
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