A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?
Remove excess clothing from the client.
Restrict the client's fluid intake.
Place a warming blanket over the client.
increase the temperature in the client's room.
The Correct Answer is A
A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Rales are described as fine crackling sounds, not high-pitched crowing.
B: Stridor is a high-pitched, wheezing sound heard primarily during inhalation and is often caused by an obstruction in the upper airway.
C: Wheezes are typically associated with asthma and are musical in nature, occurring mostly during exhalation.
D: Rhonchi are low-pitched sounds that resemble snoring and are caused by obstructions in the larger airways.
Correct Answer is B
Explanation
A: Hypoglycemia does not directly correlate with a lower heart rate.
B: A heart rate of 56/min may indicate bradycardia, which can lead to symptoms like dizziness due to decreased cardiac output and subsequently reduced cerebral perfusion.
C: A fever would typically increase the heart rate, not decrease it.
D: Cigarette smoking is more commonly associated with an increased heart rate due to stimulants like nicotine.
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