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: Talking at a rapid rate is not a good action to promote communication with a client who has hearing loss. Talking too fast can make it harder for the client to follow the conversation, lip-read, or use hearing aids. The nurse should talk at a normal rate and pause between sentences.
Choice B reason: Using short phrases is not a good action to promote communication with a client who has hearing loss. Using short phrases can make the message unclear, incomplete, or condescending. The nurse should use complete sentences and avoid jargon, slang, or abbreviations.
Choice C reason: Decreasing background noise is a good action to promote communication with a client who has hearing loss. Background noise can interfere with the client's ability to hear and understand the nurse. The nurse should reduce or eliminate any sources of noise, such as TV, radio, or other people, and choose a quiet and well-lit place to talk.
Choice D reason: Speaking in a loud voice is not a good action to promote communication with a client who has hearing loss. Speaking too loud can distort the sound, cause discomfort, or offend the client. The nurse should speak in a clear and natural voice and adjust the volume according to the client's feedback.
Correct Answer is D
Explanation
Choice A reason: Showing the client a video demonstration of peak flow meter use is a helpful teaching strategy, but it is not the first action that the nurse should take. The nurse should first assess the client's baseline knowledge and readiness to learn before providing any information or instruction.
Choice B reason: Observing the client using the peak flow meter is a way to evaluate the client's learning and skill, but it is not the first action that the nurse should take. The nurse should first determine the client's knowledge of the use of the peak flow meter and then teach the client how to use it correctly.

Choice C reason: Emphasizing the importance of the daily use of the peak flow meter is a way to motivate the client to adhere to the treatment plan, but it is not the first action that the nurse should take. The nurse should first assess the client's knowledge of the use of the peak flow meter and then explain the benefits and rationale of using it regularly.
Choice D reason: Determining the client's knowledge of the use of the peak flow meter is the first action that the nurse should take, as it follows the principle of the nursing process. The nurse should start with assessment, then proceed with planning, implementation, and evaluation. By assessing the client's knowledge, the nurse can identify the client's learning needs, gaps, and preferences, and tailor the teaching accordingly.
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