A nurse is caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?

Encourage the client to ambulate.

Give the client a cold sponge bath.

Administer antipyretics as prescribed.

Provide a cooling fan.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Encouraging the client to ambulate is not appropriate when the client has a high fever of 40°C (104°F). Ambulation requires physical exertion and can potentially worsen the client's condition, especially when they are already experiencing discomfort due to the fever.

Choice B rationale:

Giving the client a cold sponge bath might seem like a logical approach to reduce fever; however, it is not the most effective and safest method. Cold water can cause vasoconstriction and shivering, potentially increasing the body's metabolic demands and raising the temperature further. Additionally, sudden temperature changes can be uncomfortable and may not provide sustained fever reduction.

Choice C rationale:

Administering antipyretics as prescribed is the correct choice. Antipyretic medications, such as acetaminophen or ibuprofen, work to lower fever by acting on the hypothalamus, the body's temperature-regulating center. By reducing fever, the body's metabolic rate and oxygen consumption are decreased, which can help prevent complications associated with high fever, such as dehydration and discomfort.

Choice D rationale:

Providing a cooling fan can offer some comfort, but it might not be sufficient to effectively lower the client's high fever. Fans primarily work by promoting evaporative cooling, which may not be efficient when the body temperature is significantly elevated. Additionally, relying solely on a cooling fan might delay the necessary intervention of administering antipyretic medication.

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Correct Answer is C

Explanation

The correct answer is choice c. List of community resources.

Choice A rationale:

Emergency contact information is typically found in the patient’s admission records or demographic section, not in the discharge summary.

Choice B rationale:

Intake and output summary is part of the daily nursing notes or fluid balance chart, not usually included in the discharge summary.

Choice C rationale:

The discharge summary often includes a list of community resources to support the patient after discharge, such as contact information for follow-up care, support groups, or home health services.

Choice D rationale:

Basic demographic data is recorded in the patient’s initial admission records and is not typically repeated in the discharge summary.

A. Metabolic acidosis. B. Respiratory acidosis. C. Metabolic alkalosis. D. Respiratory alkalosis.

Correct Answer is C

Explanation

Choice A rationale:

Metabolic acidosis is not the correct acid-base imbalance for the given ABG results. Metabolic acidosis is characterized by a low pH (acidic), low bicarbonate (HCO3) levels, and a compensatory decrease in the PaCO2. In the provided ABG results, the pH is elevated, and both the PaCO2 and HCO3 levels are within normal ranges.

Choice B rationale:

Respiratory acidosis is also not the correct acid-base imbalance for the given ABG results. Respiratory acidosis occurs when there is an elevation in PaCO2 due to inadequate ventilation, leading to an acidic pH. In the provided ABG results, the pH is elevated, and the PaCO2 level is within normal range.

Choice C rationale:

Metabolic alkalosis is the correct acid-base imbalance for the given ABG results. Metabolic alkalosis is characterized by an elevated pH, elevated bicarbonate (HCO3) levels, and a compensatory increase in PaCO2. In this case, the pH is higher than the normal range, the HCO3 level is elevated, and the PaCO2 is also slightly increased as the body attempts to compensate.

Choice D rationale:

Respiratory alkalosis is not the correct answer based on the provided ABG results. Respiratory alkalosis is marked by an elevated pH and a decrease in PaCO2 due to excessive ventilation. In the given ABG results, the pH is elevated, but the PaCO2 is not decreased; it's within the normal range.

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A nurse is caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing data in a client's medical record. Which of the following information should the nurse expect to find in the discharge summary section?

Correct Answer is C

Explanation

A nurse is reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Correct Answer is C

Explanation

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