the nurse is caring for a 65 year old client and notes a temperature of 101f how does the nurse interpret this finding
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Nursing Elites

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The nurse is caring for a 65-year-old client and notes a temperature of 101�F. How does the nurse interpret this finding?

Correct answer: A

Rationale: A temperature of 101�F is indicative of hyperthermia, which is an elevated body temperature. Hyperthermia is commonly associated with fever or environmental factors such as excessive heat exposure. Choice B, 'A cold environment,' is incorrect as hyperthermia refers to elevated body temperature, not a cold environment. Choice C, 'Normal,' is incorrect as a temperature of 101�F is above the normal range for body temperature. Choice D, 'Hypothermia,' is incorrect as hypothermia refers to a low body temperature, not an elevated one.

2. What is a priority intervention when caring for a client in Buck’s traction?

Correct answer: D

Rationale: The correct answer is to assess skin integrity when caring for a client in Buck’s traction. This is crucial as it helps prevent pressure ulcers and other skin-related complications. Choice A is incorrect because changing the size of the traction weights should be done based on healthcare provider orders, not as needed. Choice B is incorrect because discontinuing traction should be done only under healthcare provider direction, not solely based on pain relief. Choice C is incorrect as allowing the traction weights to rest on the floor is not a priority intervention compared to assessing skin integrity.

3. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

4. A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis carinii (PCP). What is the nurse's priority assessment for this client?

Correct answer: B

Rationale:

5. A client with a bone cancer states that he is in too much pain to walk today. What should the nurse do first?

Correct answer: A

Rationale: Assessing the pain characteristics helps in managing the client’s pain effectively.

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