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

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?

A. Hyperthermia
B. A cold environment
C. Normal
D. Hypothermia

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. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?

A. Label the specimen tube
B. Put on non-sterile gloves
C. Gently remove the soiled dressings
D. Irrigate the wound

Correct answer: B

Rationale:

3. What is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV)?

A. A few missed doses per month are acceptable
B. Only specific licensed drugs are effective
C. These drugs inhibit viral replication
D. These drugs eradicate the virus

Correct answer: C

Rationale: The correct answer is that antiretroviral drugs inhibit viral replication. These medications work by interfering with the ability of the HIV virus to multiply in the body, helping to control the infection. Choice A is incorrect because consistency in taking antiretroviral drugs is crucial to their effectiveness. Missing doses can lead to treatment failure and the development of drug-resistant strains of HIV. Choice B is incorrect as there are multiple licensed drugs that are effective in treating HIV. Choice D is also incorrect as antiretroviral drugs do not kill the virus but rather suppress its replication.

4. The nurse is caring for 4 clients. What client should the nurse see first?

A. A client with multiple children visiting
B. A client with lupus asking for dinner
C. A client on Methotrexate with a fever
D. A client with chronic rheumatic pain

Correct answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.