A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?

Remove blankets from the client.

Place cold packs on the client’s axillae.

Place a fan to blow air across the client.

Give the client an alcohol sponge bath.

Answer and Explanation

The Correct Answer is A

Choice A reason: Removing blankets from the client is a good action to take. Blankets can trap heat and increase the body temperature. Removing them can help the client lose heat through radiation and convection.

Choice B reason: Placing cold packs on the client’s axillae is not a good action to take. Cold packs can cause vasoconstriction and shivering, which can increase the metabolic rate and the heat production. They can also cause discomfort and skin damage.

Choice C reason: Placing a fan to blow air across the client is not a good action to take. A fan can cause evaporation of sweat and moisture, which can lower the body temperature. However, it can also cause dehydration and electrolyte imbalance, which can worsen the client’s condition.

Choice D reason: Giving the client an alcohol sponge bath is not a good action to take. Alcohol can cause vasodilation and evaporation, which can lower the body temperature. However, it can also cause skin irritation, dryness, and absorption, which can lead to toxicity and complications.

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Correct Answer is A,B,C,E,D

Explanation

Choice 1 reason: This is the first step because cleaning the urinary meatus reduces the risk of infection and contamination.

Choice 2 reason: This is the second step because separating the labia exposes the urethral meatus and facilitates the insertion of the catheter.

Choice 3 reason: This is the third step because inserting the catheter into the urethral meatus allows the urine to drain into the collection bag.

Choice 4 reason: This is the fourth step because inflating the catheter balloon secures the catheter in place and prevents it from slipping out.

Choice 5 reason: This is the fifth step because securing the catheter to the client's thigh prevents tension and traction on the catheter and the bladder.

A. Witness the client’s signature on a consent form. B. Obtain verbal consent from the client. C. Have another nurse co-sign the client’s consent. D. Check the medical record for the client’s signature on a previous consent form.

Correct Answer is B

Explanation

Choice A reason: Witnessing the client’s signature on a consent form is not necessary for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to witness the signature for invasive or high-risk procedures that require written consent.

Choice B reason: Obtaining verbal consent from the client is the appropriate action for the nurse to take before inserting an indwelling urinary catheter. The nurse should explain the purpose, benefits, risks, and alternatives of the procedure and ensure that the client understands and agrees to it.

Choice C reason: Having another nurse co-sign the client’s consent is not required for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to have another nurse co-sign the consent for procedures that involve blood transfusions, organ donations, or research participation.

Choice D reason: Checking the medical record for the client’s signature on a previous consent form is not sufficient for verifying the client’s express consent for an indwelling urinary catheter insertion. The nurse should obtain a new consent for each procedure, as the client has the right to change their mind or refuse the treatment at any time.

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A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,E,D

Explanation

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client’s express consent for this procedure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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