A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
Measure temperature at regular intervals.
Assess for flushed, warm skin regularly.
Vary sites for temperature measurement.
Document the client's circadian rhythms.
The Correct Answer is A
Choice A Reason: This is correct because measuring temperature at regular intervals allows the nurse to monitor fever patterns and evaluate the effectiveness of interventions.
Choice B Reason: This is incorrect because assessing for flushed, warm skin regularly is not a reliable indicator of fever. Skin temperature may vary depending on environmental factors and blood flow.
Choice C Reason: This is incorrect because varying sites for temperature measurement may result in inaccurate readings. Different sites have different normal ranges and may be affected by external factors.
Choice D Reason: This is incorrect because documenting the client's circadian rhythms is not relevant to assessing fever patterns. Circadian rhythms are natural fluctuations in body functions that occur over a 24-hour cycle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is correct because this response invites the client to express her feelings and thoughts without imposing any assumptions or judgments. It also conveys empathy and respect for the client's autonomy.
Choice B Reason: This is incorrect because this response makes an inference about the client's emotional state without validating it with her. It also may sound patronizing or pitying, which can hinder rapport.
Choice C Reason: This is incorrect because this response may be perceived as intrusive or prying, especially if the client is not ready or willing to share details about her personal relationship. It also may trigger negative emotions or memories that can worsen her mood.
Choice D Reason: This is incorrect because this response may be seen as superficial or irrelevant, especially if the client did not enjoy her visit or had a conflict with her significant other. It also may imply that the nurse is avoiding or dismissing the client's current feelings.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a sputum specimen should be placed in a sealed container and labeled with the client's name, date, and time before it is removed from the room. The container should be transported to the laboratory in a plastic bag.
Choice B Reason: This is incorrect because bed linens should be placed in a leak-proof laundry bag and handled with minimal agitation before they are removed from the room. The laundry bag should be closed securely and transported to the laundry facility.
Choice C Reason: This is incorrect because the nurse's stethoscope should be cleaned and disinfected with an alcohol wipe or a germicidal solution before it is removed from the room. The stethoscope should not be shared with other clients or staff.
Choice D Reason: This is correct because paper mask and gown are disposable items that are contaminated with the client's respiratory secretions and body fluids. They should be placed in a designated biohazard bag and disposed of properly before they are removed from the room.
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