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 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.
Correct Answer is B
Explanation
Choice A rationale
Checking blood sugar levels before each meal is a good practice for managing diabetes and does not indicate a need for further teaching.
Choice B rationale
Skipping medication if blood sugar is normal indicates a misunderstanding of diabetes management. Medications should be taken as prescribed to maintain consistent blood sugar levels.
Choice C rationale
Following a balanced diet and exercising regularly are important components of diabetes management and do not indicate a need for further teaching.
Choice D rationale
Monitoring feet for cuts or sores is crucial for diabetes management to prevent complications like infections and ulcers.
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