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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A small banana contains about 8.7 mg of vitamin C, which is only 10% of the recommended daily intake for adults.
Choice B reason: A medium fresh green pear contains about 4.3 mg of vitamin C, which is only 5% of the recommended daily intake for adults.
Choice C reason: A small pink grapefruit contains about 38.4 mg of vitamin C, which is 43% of the recommended daily intake for adults. This is the highest amount of vitamin C among the four choices.
Choice D reason: A small apple with the skin contains about 8.4 mg of vitamin C, which is only 9% of the recommended daily intake for adults.
Correct Answer is A
Explanation
Choice A reason: Tightening the abdominal muscles is a good strategy to prevent back injury when lifting an object. The abdominal muscles support the spine and help maintain a neutral posture. Tightening them can reduce the stress on the back and prevent muscle strain or disc herniation.
Choice B reason: Bending at the waist is a bad strategy to prevent back injury when lifting an object. Bending at the waist can cause the spine to curve and lose its alignment. This can increase the pressure on the intervertebral discs and the spinal nerves, and lead to pain, inflammation, or nerve damage.
Choice C reason: Keeping legs straight is a bad strategy to prevent back injury when lifting an object. Keeping legs straight can limit the range of motion and the leverage of the lower body. This can force the back to do most of the work and increase the risk of injury. The nurse should bend the knees and hips and use the legs to lift the object.
Choice D reason: Holding the object away from the body is a bad strategy to prevent back injury when lifting an object. Holding the object away from the body can create a lever effect and increase the load on the back. This can cause the back muscles to overwork and fatigue, and lead to injury. The nurse should hold the object close to the body and keep it at the center of gravity.
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