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: This is incorrect because suggesting a feeding tube is premature and may alarm the son without knowing the cause of the client's poor appetite.
Choice B reason: This is incorrect because asking why the son thinks the client is not eating may imply that the son is responsible or has the answer, which may make him feel defensive or guilty.
Choice C reason: This is incorrect because dismissing the son's concern as nothing serious may make him feel unheard or invalidated, and may also delay seeking appropriate help for the client.
Choice D reason: This is correct because asking the son to tell more about what happens at mealtime is an open-ended question that shows interest and empathy, and may elicit more information about the client's condition and preferences.
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.
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.