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

To calculate how many milliliters (mL) of diazepam oral solution should be administered, you can use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL)

In this case, the desired dose is 2 mg, and the concentration of the diazepam oral solution is 5 mg/1 mL.

Dose (mL) = 2 mg / 5 mg/mL = 0.4 mL

So, the nurse should administer 0.4 mL of diazepam oral solution with each dose. The correct answer is:

A) 0.4 mL.

A. Instruct the client's loved ones that the client should not have fresh flowers in their room. B. Wear a surgical mask when within 0.9 m (3 feet) of the client. C. Place the client in a room with negative-airflow pressure. D. Instruct the client that visitors will not be allowed while they are in isolation.

Correct Answer is B

Explanation

Choice A rationale:

Instructing the client's loved ones that the client should not have fresh flowers in their room (Choice A) is not a necessary action for rubella isolation. Rubella is transmitted through respiratory droplets, and the prohibition of fresh flowers is not a relevant precaution.

Choice B rationale:

Wearing a surgical mask when within 0.9 m (3 feet) of the client (Choice B) is the correct action. Rubella is an airborne disease, and wearing a surgical mask helps prevent the spread of infectious respiratory droplets to the nurse and other individuals.

Choice C rationale:

Placing the client in a room with negative-airflow pressure (Choice C) is not specifically indicated for rubella isolation. Negative-airflow pressure rooms are typically used for diseases that require strict airborne precautions, such as tuberculosis.

Choice D rationale:

Instructing the client that visitors will not be allowed while they are in isolation (Choice D) is not entirely accurate for rubella isolation. While isolation precautions are necessary, visitors can enter the room if they are properly protected, including wearing masks and following infection control protocols.

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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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