The licensed nurse is getting report from the unlicensed assistive personnel in relation to
the morning vital signs. Which statement would indicate that the rectal temperature
needs to be taken via a different route?
A) The client was on oxygen when I took the reading.
B) I was unable to read the temperature since there was a small amount of stool on the
thermometer.
C) Since the client was confused, I took the temperature rectally.
D) The client has had diarrhea three times this morning.
Question 2
A nurse is caring for a client admitted to the healthcare facility with narcotic overdose.
The client has shallow respirations, tremors, headache, weakness, altered sensorium, and
fruity-smelling breath.
According to the arterial blood gas evaluation, the client's pH is
decreased and PCO2 is increased. Which acidbase imbalance has occurred?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis
nurse
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