A nurse is caring for a client who has a temperature of 38.7° C (101.7° F). Which of the following nursing interventions is appropriate?
Keep the client's bed linens dry.
Apply an alcohol-water solution to the client's skin.
Encourage the client to drink 1,500 mL of fluid per day.
Apply ice packs to the groin.
The Correct Answer is A
A. Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens.
B. Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever.
C. Encouraging increased fluid intake is appropriate to promote hydration, but the specific amount should be individualized based on the client's condition and needs.
D. Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Monitoring the client at least once every hour is an appropriate safety precaution to assess the client's condition and prevent falls.
B. Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention.
C. Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate.
D. Keeping four side rails up while the client is in bed can be a restraint and may increase the risk of injury. It is not a recommended approach for fall prevention.
Correct Answer is D
Explanation
A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.
C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.
D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.