A high school student arrives at the school nurse's office complaining of headache, aches, pains, and general fatigue. The nurse observes the student's face is flushed and decides to obtain a set of vital signs. Which of the following vital signs is most likely to be abnormal?

Correct Answer: B

Rationale: The symptoms (headache, aches, pains, fatigue, flushed face) suggest a possible febrile illness (e.g., flu). Temperature is most likely to be abnormal, as fever is a common cause of these symptoms and flushing, whereas BP, pulse, and oxygen saturation are less directly linked unless secondary complications arise.

Correct Answer: D

Rationale: If a patient bites a thermometer, the priority is to remove glass debris from the mouth (D) to prevent injury or ingestion. Mercury thermometers are rare today, but if present, further steps follow; options A-C are irrelevant or harmful.

Correct Answer: B

Rationale: Pressure care prevents ulcers via repositioning and skin care. Dry skin (A) helps but isn’t the goal, no movement (C) worsens risk, and compresses (D) are irrelevant.

Correct Answer: B

Rationale: Repositioning and devices relieve pressure to prevent ulcers. Static positioning (A) worsens risk, compresses (C) and cold water (D) are irrelevant.

Correct Answer: A

Rationale: Rectal lavage clears the rectum or relieves constipation. It doesn’t hydrate (B), prevent sores (C), or administer meds (D).