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

Correct Answer: B

Rationale: Temperature drops at night (96.8°F) due to circadian rhythm, a normal variation from 98.6°F daytime. Infection isn't indicated. Blanket or meds are unnecessary without symptoms. Choice B is correct, per nursing knowledge of diurnal fluctuations.

Correct Answer: A

Rationale: 90/60 mmHg can be normal for some , especially if asymptomatic, and should be documented. Waiting is unnecessary without symptoms. Fluids or vasopressors need clinical context. Choice A is correct, per the explanation, reflecting nursing judgment.

Correct Answer: C

Rationale: Blood pressure is a core vital sign, alongside temperature, pulse, and respiration, reflecting cardiovascular health by measuring arterial force. Mental status is assessed separately, often via neurological exams, not as a vital sign. Visual acuity evaluates eyesight, unrelated to immediate physiological stability. Urinary output monitors kidney function but isn't a standard vital sign, though it's tracked in critical care. The answer key confirms C, aligning with nursing fundamentals (e.g., Taylor's text), where vital signs are immediate indicators of life-sustaining functions, distinguishing BP's role in routine assessments from other metrics.

Correct Answer: A

Rationale: Rectal provides the most accurate core temperature, per the answer key, reflecting internal heat near the hypothalamus. Oral , axillary , and forehead are less precise. Nurses choose rectal for its reliability in critical assessments despite invasiveness.

Correct Answer: B

Rationale: Dorsal recumbent is suitable for abdominal assessment, but the answer key lists B as incorrect herelikely a typo (intended C or D). Kneechest and Sims distort abdominal access. Supine is standard. Rationale assumes C/D intent, per Taylor's positioning guidelines.