A patient has an elevated temperature. The nurse assesses the patient and finds the skin flushed and very warm. The patient is oriented to person, place, time, and situation, and expresses severe fatigue. The most appropriate nursing action at this time would be to:
Remove blankets and offer fluids
Increase the patient's activity
Place ice bags on the patient's skin
Decrease the patient's intake
The Correct Answer is A
Choice A reason: When a patient has an elevated temperature, the body is attempting to cool down through vasodilation, which is why the skin may appear flushed and feel warm. Removing excess blankets can help facilitate the body's natural cooling process. Offering fluids is also crucial as fever can lead to dehydration, especially if there is sweating. Adequate hydration helps regulate body temperature and replaces fluids lost through sweating. The normal body temperature range is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). When the body temperature rises above this range, interventions such as removing blankets and providing fluids can be effective in reducing fever.
Choice B reason: Increasing the patient's activity is not advisable when they have an elevated temperature and are experiencing severe fatigue. Activity generates heat and can raise body temperature further, exacerbating the fever. Rest is recommended to conserve energy and reduce metabolic demand, which can help lower the body temperature.
Choice C reason: The use of ice bags can be a rapid cooling measure but must be used with caution. Direct application of ice to the skin can cause vasoconstriction and shivering, which can actually increase the body's core temperature. It is generally reserved for hyperthermia or heatstroke when immediate cooling is necessary. For a simple fever, less aggressive cooling measures are usually preferred.
Choice D reason: Decreasing the patient's intake is not appropriate unless there is a specific contraindication, such as vomiting or risk of aspiration. Adequate nutrition supports the immune system and provides the energy needed for the body to combat the underlying cause of the fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Putting on sterile gloves is not necessary before palpating the abdomen. Sterile gloves are typically used for procedures that require an aseptic technique, such as inserting a catheter or performing a surgical procedure. Palpation of the abdomen is a non-sterile procedure, and clean gloves are usually sufficient to prevent the transmission of microorganisms.
Choice B reason: Elevating the client's head is not a standard preparatory step before palpating the abdomen. While it may be necessary to adjust the client's position for comfort or to assess certain areas, the head elevation is not specifically related to the palpation process. The client should be in a supine position with knees slightly bent to relax the abdominal muscles, which facilitates palpation.
Choice C reason: Percussion of all four quadrants is part of the abdominal assessment but is not the step that precedes palpation. Percussion is used to assess the size and density of abdominal organs, detect the presence of fluid or gas, and evaluate tenderness. However, the correct sequence of abdominal assessment is inspection, auscultation, percussion, and then palpation.
Choice D reason: Auscultating bowel sounds is the correct action before palpating the abdomen. This is because palpation can alter bowel motility, which may change the sounds heard. Auscultation should be performed after inspection and before percussion and palpation to obtain an accurate assessment of bowel activity. Normal bowel sounds range from 5 to 30 per minute and are characterized by clicks and gurgles.
Correct Answer is D
Explanation
Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.
Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.
Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.
Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.
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