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

Choice A rationale:

The neighbor is not authorized to provide consent for the client's procedure. The durable power of attorney for health care typically designates someone to make medical decisions when the client is unable to do so, but the neighbor's role may not extend to medical procedure consent.

Choice B rationale:

The client's spouse might have a legal standing to make decisions for the client, but the durable power of attorney for health care typically takes precedence over the spouse's decision-making authority in situations where it has been established.

Choice C rationale:

The provider, in this case, the medical doctor or healthcare professional performing the endoscopy, has the authority to obtain consent for the procedure. Informed consent is a crucial ethical and legal requirement, and the provider must ensure that the client or their designated decision-maker understands the procedure, its risks, and benefits before proceeding.

Choice D rationale:

A member of the facility's ethics committee does not typically have the authority to provide consent for a specific medical procedure on behalf of an incapacitated client. The ethics committee's role is to provide guidance on ethical dilemmas and issues but not to provide individual procedural consent.

A. Place both feet apart and shift from the back to the front leg when moving the client up in bed. B. Position the client's arms at their sides prior to moving them up in bed. C. Elevate the head of the client's bed 30° prior to moving the client. D. Bend at the waist when grasping the draw sheet when moving the client up in bed.

Correct Answer is A

Explanation

Choice A rationale:

This choice reflects the correct technique for maintaining balance and using proper body mechanics when assisting with moving a client up in bed. Shifting weight from the back to the front leg while keeping the feet apart provides a stable base and reduces the risk of injury to the nurse.

Choice B rationale:

Positioning the client's arms at their sides before moving them up in bed is not a necessary step and may not contribute significantly to the process. The primary focus should be on proper body mechanics and the use of assistive devices, such as a draw sheet, to ensure safe patient handling.

Choice C rationale:

Elevating the head of the client's bed 30° is not directly related to the task of moving the client up in bed using a draw sheet. While head elevation might have other clinical indications, it does not impact the technique of assisting with repositioning.

Choice D rationale:

Bending at the waist when grasping the draw sheet is incorrect body mechanics and can lead to strain on the nurse's back. Proper technique involves using the legs to bend and lift while keeping the back straight, reducing the risk of injury.

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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 caring for a client who has chosen a neighbor as their designee in their durable power of attorney for health care. The client is incapacitated and is scheduled for an endoscopy. The nurse should request that which of the following individuals provide consent for the procedure?

Correct Answer is C

Explanation

A nurse is assisting a coworker with moving a client up in bed using a draw sheet. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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