A nurse assesses an oral temperature for an adult patient and records that the patient is afebrile. What would be the nurses best response to this finding?

Correct Answer: D

Rationale: Afebrile means the patient has no fever, indicating a temperature within the normal range for an adult (typically 36.6°C to 38°C or 97.9°F to 100.4°F). When a nurse records a patient as afebrile, it suggests the absence of an elevated temperature that would require intervention. Choice A (checking for antipyretics) is unnecessary unless theres evidence of recent fever management, which isnt indicated here. Choice B (reporting to the provider) is not warranted for a normal finding unless other symptoms suggest a need for escalation. Choice C (using a different method) is redundant since the oral method is reliable and the result is normal. Choice D is correct because no further action is needed for a temperature within normal limits. This reflects standard nursing practice where routine findings dont prompt additional steps unless contextual factors suggest otherwise.

Correct Answer: C

Rationale: Post-cardiac arrest, tympanic provides a quick, non-invasive core temperature estimate, critical for monitoring hypothermia or hyperthermia in resuscitation. Oral risks inaccuracy post-arrest. Rectal is invasive and slow. Temporal is less reliable in emergencies. Choice C is correct, aligning with ACLS emphasis on rapid, safe temperature assessment.

Correct Answer: A

Rationale: Vital signs measure essential physiological functionstemperature, pulse, respiration, blood pressure, and oxygen saturationreflecting the body's basic operations . Urination frequency isn't a vital sign, though it's monitored in specific contexts. Weight and height are anthropometric, not vital signs. BMI is a calculated health indicator, not a direct measurement. Choice A is correct, aligning with nursing fundamentals defining vital signs as core indicators of life-sustaining processes, routinely assessed to evaluate health status and detect deviations requiring intervention.

Correct Answer: C

Rationale: BP readings show systolic (top, ventricular contraction) and diastolic (bottom, relaxation) pressures , in mmHg. Oxygen saturation and pulse are separate. Diastolic over systolic reverses order. Millimeters and mercury is the unit, not the terms. Choice C is correct, per standard BP notation (e.g., 120/80 mmHg), a foundational nursing concept for documenting cardiac workload.

Correct Answer: A

Rationale: The best response in this scenario is option A) Assess the patient's apical pulse to obtain the heart rate. This is the correct choice because in a situation where obtaining the heart rate from the right radial pulse is difficult, the apical pulse provides an accurate alternative. The apical pulse is auscultated at the apex of the heart using a stethoscope, allowing for an accurate assessment of the heart rate. Option B) Obtain the heart rate from right and left radial sites is incorrect because if the right radial pulse is difficult to palpate, it is likely that the left radial pulse would also be challenging to locate. Option C) Obtain the heart rate using the oximeter probe is not the most appropriate choice in this situation because the oximeter probe measures oxygen saturation, not heart rate. Option D) Perform a complete assessment of all pulses is not necessary in this scenario as the focus is on obtaining the heart rate accurately. A complete pulse assessment may be indicated for a different purpose, but in this case, assessing the apical pulse is the most direct and effective method. Educationally, understanding alternative methods for assessing heart rate is crucial for healthcare providers to ensure accurate monitoring of vital signs postoperatively. Practicing assessment techniques helps develop clinical reasoning skills and ensures high-quality patient care.