NCLEX Thermoregulation Questions i
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.
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The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1. The client's body temperature is 98° F. 2. The client's fingers and toes are cool to touch. 3. The client remains in a fetal position when in bed. 4. The client complains of coolness in the hands and feet only.
1
Which are modes of heat loss? Select all that apply. 1. Radiation 2. Urination 3. Convection 4. Conduction 5. Evaporation
1, 3, 4, 5
The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Venous insufficiency 4. Arterial insufficiency
2
The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign that would indicate that brainstem involvement occurred during the surgical procedure? 1. Inability to swallow 2. Elevated temperature 3. Altered hearing ability 4. Orthostatic hypotension
2
A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the fundus. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position.
3
The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. The nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in which structure? 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus
4
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer
3
The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1. Radiation 2. Convection 3. Conduction 4. Evaporation
3
A client's baseline vital signs are as follows: temperature 98.8° F oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F. Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? 1. Respiratory rate of 12 breaths/min 2. Respiratory rate of 16 breaths/min 3. Respiratory rate of 18 breaths/min 4. Respiratory rate of 22 breaths/min
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A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse anticipates that the client will exhibit which findings on assessment of vital signs? 1. Increased heart rate and increased blood pressure 2. Increased heart rate and decreased blood pressure 3. Decreased heart rate and increased blood pressure 4. Decreased heart rate and decreased blood pressure
4
The nurse has just administered ibuprofen (Motrin) to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate (aspirin) in 4 hours. 4. Remove excess clothing and blankets from the child.
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