A nurse is caring for a client who has a rectal temperature of 35°C (95°F). Which of the following actions should the nurse take?
Decrease the temperature in the client's room.
Request a prescription for an antipyretic medication.
Place a cooling fan near the client.
Place a warming blanket over the client.
The Correct Answer is D
A reason:
Decreasing the temperature in the client's room is incorrect. The client is already hypothermic and needs to be warmed, not further cooled.
B reason:
Requesting a prescription for an antipyretic medication is inappropriate. Antipyretics are used to lower fever, not to treat hypothermia.
C reason:
Placing a cooling fan near the client is incorrect and would exacerbate hypothermia.
D reason:
Placing a warming blanket over the client is correct. This action helps to gradually raise the client's body temperature to a safe level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A reason:
Calling the provider is unnecessary for an apical heart rate of 100/min unless there are other concerning symptoms. This heart rate is within the upper range of normal, especially if the client is active or anxious.
B reason:
Preparing the client for a chest x-ray is not warranted solely based on a heart rate of 100/min. Other clinical indications would be needed to justify this diagnostic test.
C reason:
Asking another nurse to verify the heart rate is not required. A heart rate of 100/min is within the normal range and does not typically necessitate double-checking unless there are irregularities or other concerns.
D reason:
Documenting this as an expected finding is correct. An apical heart rate of 100/min is within the normal range, especially in situations of mild exertion or stress.
Correct Answer is A
Explanation
A reason:
Patients with droplet diseases such as measles require re-education. Measles is an airborne disease, not droplet, and requires airborne precautions, including an N95 mask.
B reason:
Washing hands with soap and water, not hand sanitizer, for C. diff, norovirus, and rotavirus is correct. These infections require thorough hand washing to remove spores effectively.
C reason:
Ensuring patients in droplet precaution wear a surgical mask when being transported is correct. This helps to prevent the spread of infectious droplets.
D reason:
Wearing a gown and gloves when entering a room of a patient in contact precautions is correct. This prevents the spread of infections through direct and indirect contact.
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