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
Serum amylase is typically elevated in acute pancreatitis. It is one of the key diagnostic markers for this condition.
Choice B rationale
Serum potassium levels are not typically elevated in acute pancreatitis. Potassium levels are more commonly associated with kidney function and electrolyte balance.
Choice C rationale
Serum calcium levels are usually decreased, not elevated, in acute pancreatitis. Hypocalcemia can occur due to fat saponification in the pancreas.
Choice D rationale
Serum sodium levels are not typically elevated in acute pancreatitis. Sodium levels are more related to overall fluid balance and kidney function.

A. Sepsis. B. Hypovolemic shock. C. Myocardial infarction. D. Pulmonary embolism.

Correct Answer is A

Explanation

Choice A rationale
Sepsis is a systemic inflammatory response to infection, often characterized by fever (temperature of 38°C or higher) and tachycardia (heart rate of 120 beats per minute or higher). These symptoms indicate the body’s response to a severe infection.
Choice B rationale
Hypovolemic shock is caused by significant fluid loss, leading to decreased blood volume and perfusion. It typically presents with hypotension and tachycardia, but not necessarily fever.
Choice C rationale
Myocardial infarction (heart attack) is characterized by chest pain, shortness of breath, and other symptoms, but fever and tachycardia are not primary indicators.
Choice D rationale
Pulmonary embolism involves a blockage in the pulmonary arteries, leading to symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, but not typically fever.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with acute pancreatitis. Which laboratory result would the nurse expect to find elevated?

Correct Answer is A

Explanation

A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?

Correct Answer is A

Explanation

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