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 nurse assesses an area of skin over a bony prominence. What finding would be most concerning?

A. Redness
B. Non-blanching
C. Blanching
D. Warmth

Correct answer: A

Rationale:

3. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?

A. PAPR mask
B. Sterile gloves
C. Gown
D. Surgical mask

Correct answer: C

Rationale:

4. What is the priority nursing diagnosis after surgery to repair a fracture?

A. Disturbed body image
B. Risk for infection
C. Risk for impaired skin integrity
D. Acute pain

Correct answer: B

Rationale: The correct answer is B: Risk for infection. After surgery to repair a fracture, the priority nursing diagnosis is to monitor for the risk of infection to promote proper healing. Infections can significantly delay the healing process and lead to further complications. Choices A, C, and D are not the priority immediately post-surgery. Disturbed body image, risk for impaired skin integrity, and acute pain may be concerns but are not the priority in the immediate post-operative period following fracture repair.