The nurse is working the night shift on a surgical unit and notices that the patient's temperature is 96.8°F (36°C), whereas at 4:00 PM the preceding day, it was 98.6°F (37°C). What should the nurse do?

Correct Answer: D

Rationale: A temperature of 96.8°F (36°C) is slightly low but within normal diurnal variation (lowest at night). Waiting 30 minutes to recheck confirms if it's a trend or artifact, avoiding overreaction. Calling the provider is premature for a non-critical value without symptoms. Lowering it further is illogical for hypothermia. Adding a blanket assumes hypothermia without confirmation. Choice D is correct, reflecting nursing judgment to monitor trends, aligning with circadian temperature dips and post-surgical assessment protocols.

Correct Answer: C

Rationale: Vital signs reflect homeostasis , the body's ability to maintain internal stability (e.g., temperature, heart rate). Food processing affects digestion, not vital signs directly. Weight and height inform growth or BMI, not homeostasis monitoring. ‘None of the above' dismisses the correct link. Choice C is correct, as vital signs are physiological markers of homeostatic balance, a principle nurses use to assess health and guide care, per basic pathophysiology.

Correct Answer: C

Rationale: Baseline vital signs provide a reference to assess current RR 26 and SpO2 92% against prior recovery, guiding interventions. Activity and meds inform care but not priority. Dyspnea perception is subjective, less critical than objective trends. Choice C is correct, per nursing process emphasizing baseline data for planning effective respiratory care.

Correct Answer: B

Rationale: In caring for an infant and obtaining vital signs, it is crucial to select the correct site for pulse assessment. The correct answer is B) Brachial artery. The brachial artery is the most suitable site for assessing an infant's pulse due to its accessibility and proximity to the heart, providing a more accurate representation of the infant's cardiac output. Choosing A) Radial artery for an infant's pulse may not be ideal as it is more commonly used in adults. The radial pulse may be difficult to locate in infants due to their small size and developing circulatory system. Option C) Femoral artery is not typically used for routine pulse assessment in infants and may be more challenging to access in clinical settings. Option D) Popliteal artery is located behind the knee and is not recommended for pulse assessment in infants due to its location and difficulty in obtaining an accurate reading. Educationally, understanding the rationale behind selecting the appropriate pulse site in infants is essential for providing safe and effective care, ensuring accurate vital sign measurements, and promoting optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is option C: Initiate cardiac monitoring for atrial fibrillation. An irregularly irregular pulse, with no discernible pattern, is a classic characteristic of atrial fibrillation, a common cardiac arrhythmia. By initiating cardiac monitoring, the nurse can further investigate the nature of the irregular pulse and determine if the client is indeed experiencing atrial fibrillation. Option A: Documenting the finding as a normal variation is incorrect because an irregularly irregular pulse is not considered a normal variation and warrants further investigation. Option B: Reassessing the pulse rate after 15 minutes is not the most appropriate action in this situation. Given the irregular nature of the pulse, immediate further assessment and intervention are needed. Option D: Instructing the client to perform deep breathing exercises is also not the best course of action for an irregularly irregular pulse. While deep breathing exercises can sometimes help in certain situations, they are not the priority when dealing with a potentially serious cardiac arrhythmia like atrial fibrillation. Educationally, it is crucial for nurses to recognize abnormal findings during vital sign assessments and take appropriate actions. Understanding the significance of irregular pulse patterns can lead to early detection and management of cardiac issues, improving patient outcomes. By knowing when to escalate care, nurses play a vital role in ensuring patient safety and well-being.