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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The patient's spouse reporting experiencing marital issues is a perfect example of secondary information as it comes from someone other than the patient and might affect the patient's care or emotional well-being indirectly.
B. The patient reports a history of chest pain, is an example of primary information. This is because the patient directly reports the symptoms of their health condition.
C. The patient complaining of chronic constipation is an example of primary information. This is because the patient is directly reporting their own health condition.

D. The patient verbalizes anxiety about hospitalization is also primary information, directly provided by the patient concerning their feelings about the current care environment.

A. A sonorous wheeze upon inspiration. B. Musical or whistling sounds with respirations. C. Noisy, snoring sounds during respirations. D. Sounding like hair being rubbed between the thumb and index fingers.

Correct Answer is D

Explanation

A: Sonorous wheezes are low-pitched sounds and do not describe fine rales.

B: Musical or whistling sounds typically describe wheezes which are continuous and not the discontinuous sound of rales.
C: Noisy, snoring sounds are characteristic of rhonchi, not rales.

D: Fine rales are high-pitched, brief, and discontinuous crackling sounds that are often likened to the sound of hair being rubbed between fingers, indicative of fluid in the small airways.

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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?

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