NURS 270 Unit 4 2025 LATEST UPDATED | COMPREHENSIVE
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a
tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when
the child's nurse
A. Places a hypothermia blanket at the bedside.
B. Adjusts the bed to the Trendelenburg position.
C. Obtains electronic equipment for monitoring the vital signs.
D. Secures a pump to administer the ordered intravenous fluids. - Correct answer-B. Adjusts the bed to
the Trendelenburg position.
It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow
to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a
craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the
temperature becomes precipitously elevated. Monitoring vital signs is a critical component of
postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of
cerebral edema.
A patient with hypothermia is brought to the emergency department. The nurse should explain to the
family members that treatment will include
A. Core rewarming with warm fluids.
B. Ambulation to increase metabolism.
C. Frequent oral temperature assessment.
D. Gastric tube feedings to increase fluids. - Correct answer-A. Core rewarming with warm fluids.
Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the
preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not
,NURS 270 Unit 4 2025 LATEST UPDATED | COMPREHENSIVE
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
the most accurate assessment of core temperature because of environmental influences. Warmed oral
feedings are advised; gastric gavage is unnecessary.
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?
A. Dyspnea.
B. Precordial pain.
C. Increased pulse rate.
D. Elevated blood pressure. - Correct answer-C. Increased pulse rate.
The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may
increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not
necessarily elevated in fever.
A homeless person is brought to the emergency department after prolonged exposure to cold weather.
The nurse would assess the patient for manifestations of hypothermia, including
A. Stupor.
B. Erythema.
C. Increased anxiety.
D. Rapid respirations. - Correct answer-A. Stupor.
Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not
erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient
would be unable to focus on anxiety-producing aspects of the situation. Respirations would be
decreased.
A priority nursing intervention for a patient with hyperthermia would be
,NURS 270 Unit 4 2025 LATEST UPDATED | COMPREHENSIVE
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
A. Initiating seizure precautions.
B. Limiting oral intake.
C. Providing a blanket.
D. Removing excess clothing. - Correct answer-D. Removing excess clothing.
Rationale
The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a
high body temperature, but seizure precautions should not be the first intervention. Oral intake,
especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of
dehydration. Blanketing, like clothing, should be removed.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia
when the patient demonstrates
A. Increased respirations.
B. Rapid pulse rate.
C. Red, sweaty skin.
D. Slow capillary refill. - Correct answer-D. Slow capillary refill.
With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia.
The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
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.
, NURS 270 Unit 4 2025 LATEST UPDATED | COMPREHENSIVE
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids. - Correct answer-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. - Correct answer-4
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 - Correct answer-2
A client with a neurological problem is experiencing hyperthermia. Which measure would be least
appropriate for the nurse to use in trying to lower the client's body temperature?
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
3. Placing ice packs in the axilla and groin areas
4. Administering acetaminophen (Tylenol) per protocol - Correct answer-3
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a
tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when
the child's nurse
A. Places a hypothermia blanket at the bedside.
B. Adjusts the bed to the Trendelenburg position.
C. Obtains electronic equipment for monitoring the vital signs.
D. Secures a pump to administer the ordered intravenous fluids. - Correct answer-B. Adjusts the bed to
the Trendelenburg position.
It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow
to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a
craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the
temperature becomes precipitously elevated. Monitoring vital signs is a critical component of
postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of
cerebral edema.
A patient with hypothermia is brought to the emergency department. The nurse should explain to the
family members that treatment will include
A. Core rewarming with warm fluids.
B. Ambulation to increase metabolism.
C. Frequent oral temperature assessment.
D. Gastric tube feedings to increase fluids. - Correct answer-A. Core rewarming with warm fluids.
Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the
preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not
,NURS 270 Unit 4 2025 LATEST UPDATED | COMPREHENSIVE
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
the most accurate assessment of core temperature because of environmental influences. Warmed oral
feedings are advised; gastric gavage is unnecessary.
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia?
A. Dyspnea.
B. Precordial pain.
C. Increased pulse rate.
D. Elevated blood pressure. - Correct answer-C. Increased pulse rate.
The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may
increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not
necessarily elevated in fever.
A homeless person is brought to the emergency department after prolonged exposure to cold weather.
The nurse would assess the patient for manifestations of hypothermia, including
A. Stupor.
B. Erythema.
C. Increased anxiety.
D. Rapid respirations. - Correct answer-A. Stupor.
Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not
erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient
would be unable to focus on anxiety-producing aspects of the situation. Respirations would be
decreased.
A priority nursing intervention for a patient with hyperthermia would be
,NURS 270 Unit 4 2025 LATEST UPDATED | COMPREHENSIVE
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
A. Initiating seizure precautions.
B. Limiting oral intake.
C. Providing a blanket.
D. Removing excess clothing. - Correct answer-D. Removing excess clothing.
Rationale
The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a
high body temperature, but seizure precautions should not be the first intervention. Oral intake,
especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of
dehydration. Blanketing, like clothing, should be removed.
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia
when the patient demonstrates
A. Increased respirations.
B. Rapid pulse rate.
C. Red, sweaty skin.
D. Slow capillary refill. - Correct answer-D. Slow capillary refill.
With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia.
The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.
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.
, NURS 270 Unit 4 2025 LATEST UPDATED | COMPREHENSIVE
QUESTIONS WITH 100% RATED ANSWERS | GUARANTEED
3. Notify the health care provider (HCP).
4. Increase hydration by encouraging oral fluids. - Correct answer-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. - Correct answer-4
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 - Correct answer-2
A client with a neurological problem is experiencing hyperthermia. Which measure would be least
appropriate for the nurse to use in trying to lower the client's body temperature?
1. Giving tepid sponge baths
2. Applying a hypothermia blanket
3. Placing ice packs in the axilla and groin areas
4. Administering acetaminophen (Tylenol) per protocol - Correct answer-3
