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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”
Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.
Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.
Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.
Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.
Correct Answer is A
Explanation
Choice A rationale:
In the "background" portion of the SBAR communication tool, the nurse should include the client's present condition. This information provides the provider with context and a clear understanding of the client's current status. It helps the provider to have a baseline understanding before moving on to the assessment and recommendation stages of the communication. Including the client's present condition allows the provider to quickly grasp the urgency and severity of the situation, enabling them to make informed decisions regarding the client's care.
Choice B rationale:
Suggestions for the provider regarding client care are typically included in the "assessment" or "recommendation" portions of the SBAR communication tool, rather than the "background" portion. The "background" portion is focused on providing information about the current situation and the client's present condition, setting the stage for the rest of the communication.
Choice C rationale:
Physical findings are part of the assessment and observation of the client's current condition. While important, these findings are better suited for the "assessment" portion of the SBAR communication. The nurse should summarize the physical findings in the "assessment" section after providing the context in the "background" section.
Choice D rationale:
Previous treatments are also relevant information, but they belong in the "assessment" or "background" portions of the SBAR communication tool. The nurse should provide the provider with information about the client's current condition before discussing previous treatments, as the provider needs to know the current situation before considering the relevance of past interventions.
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