Author Question: Of the following patients, which one is the best candidate to have his temperature taken orally? ... (Read 29 times)

brutforce · **on:** Jul 23, 2018

Of the following patients, which one is the best candidate to have his temperature taken orally?

a. A 27-year-old postoperative patient with an elevated temperature
b. A teenage boy who has just returned from outside for a smoke
c. An 87-year-old confused male suspected of hypothermia
d. A 20-year-old male with a history of epilepsy

Question 2

The nurse is caring for a patient who complains of feeling light-headed and woozy. The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do?

a. Call the physician immediately.
b. Perform an apical/radial pulse assessment.
c. Apply more pressure to the radial artery to assess the pulse.
d. Use his thumb to detect the patient's pulse.

blazinlyss · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A
An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.

Answer to Question 2

ANS: B
If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the physician. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Fingertips are the most sensitive parts of the hand to palpate arterial pulsations. The thumb has a pulsation of its own that interferes with accuracy.