A nurse is caring for a client with a body temperature of 38°C (100.4°F). Which of the following interventions should the nurse prioritize?

Administer antipyretic medication as prescribed.

Encourage fluid intake to prevent dehydration.

Monitor vital signs every 4 hours.

Apply a cooling blanket to reduce fever.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.
Choice B rationale
Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.
Choice C rationale
Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.
Choice D rationale
Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.

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Correct Answer is A

Explanation

Choice A rationale
The absence of burning epigastric pain after eating indicates that the treatment for peptic ulcer disease (PUD) secondary to H. pylori has been effective. This suggests that the ulcer has healed and the inflammation has subsided.
Choice B rationale
Coffee-ground emesis indicates the presence of blood in the vomit, which suggests ongoing bleeding and is not a sign of effective treatment for PUD.
Choice C rationale
A decrease in alcohol intake is beneficial for overall health but does not directly indicate the effectiveness of treatment for PUD secondary to H. pylori.
Choice D rationale
Normalization of hemoglobin levels is important but does not specifically indicate the effectiveness of treatment for PUD secondary to H. pylori. The primary indicator would be the resolution of symptoms such as burning epigastric pain.

A. Maintain the client in a supine position. B. Maintain a high-Fowler’s position when the client is in bed. C. Elevate the stump on a pillow. D. Position the client on the abdomen for 20 to 30 minutes twice a day.

Correct Answer is D

Explanation

Choice D rationale

Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.

Choice A rationale

Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.

Choice B rationale

Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.

Choice C rationale

Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.

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A nurse is caring for a client with a body temperature of 38°C (100.4°F). Which of the following interventions should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

Which assessment data would indicate to the nurse that pharmacologic treatment with antibiotics and antacids has been effective for the patient diagnosed with peptic ulcer disease (PUD) secondary to H. pylori?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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