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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Post-renal acute kidney injury (AKI) is caused by obstruction of urine flow, leading to decreased urine output, but it does not typically cause crackles in the lungs.
Choice B rationale
Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH), but it does not cause crackles in the lungs.
Choice C rationale
Syndrome of inappropriate antidiuretic hormone (SIADH) involves excessive release of ADH, leading to water retention and hyponatremia, but it does not cause crackles in the lungs.
Choice D rationale
Congestive heart failure (CHF) can lead to fluid accumulation in the lungs (crackles) and decreased urine output due to poor cardiac function and renal perfusion.
Correct Answer is D
Explanation
Choice A rationale
Acute respiratory distress syndrome (ARDS) is characterized by severe hypoxemia and respiratory distress, often requiring mechanical ventilation. It is not typically associated with a mild fever and increased respiratory rate.
Choice B rationale
Chronic obstructive pulmonary disease (COPD) is a chronic condition characterized by airflow limitation and respiratory symptoms, but not typically associated with a mild fever.
Choice C rationale
Pulmonary edema involves fluid accumulation in the lungs, leading to respiratory distress and hypoxemia, but not typically associated with a mild fever.
Choice D rationale
Pneumonia is an infection of the lungs causing fever (37.5°C), increased respiratory rate (28 breaths per minute), and other respiratory symptoms. It is the most likely condition given the symptoms.
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