A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Encourage fluid intake of 2,500 mL/day.

Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).

Immerse the client in cold water.

Assist the client to ambulate.

Answer and Explanation

The Correct Answer is A

Choosing the best intervention for a client with fever due to infection:

The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:

a. Encourage fluid intake of 2,500 mL/day.

Rationale:

Pros: Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
Cons: While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.

b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).

Rationale:

Cons: Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.

c. Immerse the client in cold water.

Rationale:

Cons: Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.

d. Assist the client to ambulate.

Rationale:

Cons: While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.

Therefore, the most appropriate intervention for a client with fever due to infection is:

a. Encourage fluid intake of 2,500 mL/day.

Remember:

Individualize care based on the client's specific needs and preferences.
Monitor the client's response to interventions and adjust as needed.
Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.

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Correct Answer is A

Explanation

Choice A rationale:

Instructing the client to remain supine for 10 minutes after inserting a vaginal suppository helps ensure proper absorption of the medication. This position allows the suppository to stay in contact with the vaginal mucosa, promoting optimal drug absorption. This is an essential nursing action to maximize the therapeutic effect of the medication.

Choice B rationale:

Applying sterile gloves after cleansing the perineal area is not necessary when administering a vaginal suppository. While maintaining cleanliness is important, the use of sterile gloves is not typically required for this procedure. Clean, non-sterile gloves are sufficient to maintain aseptic technique during the administration.

Choice C rationale:

Inserting the suppository 3 to 4 cm (1 to 1.5 in) into the vagina is an appropriate depth for vaginal suppository insertion. The nurse should follow this guideline to ensure that the medication reaches the appropriate location within the vaginal canal, optimizing absorption and effectiveness.

Choice D rationale:

Placing the client in the lateral semi-prone recumbent position is not a standard position for administering a vaginal suppository. The suppository is typically administered with the client lying on their back (supine) to facilitate insertion and medication absorption. Placing the client in the position described would not provide the optimal angle for insertion.

A. Provide oral replacement solution. B. Obtain a prescription for antidiarrheal medication. C. Offer the client a sitz bath. D. Collect a specimen of the client's stool.

Correct Answer is A

Explanation

Choice A rationale:

Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.

Choice B rationale:

Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.

Choice C rationale:

Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.

Choice D rationale:

Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.

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A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Choosing the best intervention for a client with fever due to infection:

Nursing Test Bank

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