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 D
Explanation
Choice A reason: Directing the partner to leave and return once postmortem care is complete is not respectful of the partner's feelings and wishes. The nurse should allow the partner to stay and participate in the postmortem care if they desire.
Choice B reason: Instructing the partner not to touch the client’s body is not compassionate or supportive of the partner's grief. The nurse should encourage the partner to touch, hold, or kiss the client’s body as a way of saying goodbye.
Choice C reason: Placing the client’s personal belongings in a safe location in the facility is a necessary action, but not the priority. The nurse should first ask the partner if they want to keep any of the belongings or give them to the nurse for safekeeping.
Choice D reason: Asking the partner about any rituals they would like to be performed is the most appropriate action. The nurse should respect and facilitate the partner's cultural, religious, or personal preferences for postmortem care.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because injecting air into the ampule is not necessary and may cause the medication to spill or spray.
Choice B reason: This is incorrect because cleansing the tip of the ampule with an alcohol swab after opening is not effective and may contaminate the medication.
Choice C reason: This is correct because using a filter needle to aspirate the medication prevents glass particles from entering the syringe and the client.
Choice D reason: This is incorrect because adding diluent to the medication may alter its concentration and potency, and should only be done if instructed by the manufacturer or the prescriber.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.