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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Cleaning the incision with soap and water is not typically recommended as it can disrupt the healing process and may lead to irritation or infection. The incision should be kept clean and dry, and any cleaning should be done according to the surgeon's instructions.

Choice B reason: Performing hand hygiene before dressing changes is essential in preventing incisional infections. Hand hygiene is one of the most effective ways to prevent the spread of infections, including those at surgical sites.

Choice C reason: Protective isolation is used for immunocompromised patients to protect them from infections, not typically for postoperative patients unless they are at high risk for infection due to other conditions.

Choice D reason: Allowing the wound to air can be part of the healing process, but it must be done carefully and under the guidance of healthcare professionals to ensure that the wound is protected from contamination.

A. Pulse 82/min, client sitting in a chair B. Temperature 36.9°C (98.4°F) C. Respirations auscultated, even at 22/min, client supine D. Blood pressure 108/68 mm Hg

Correct Answer is A

Explanation

Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.

Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.

Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.

Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?

Correct Answer is B

Explanation

For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

Correct Answer is A

Explanation

A nurse is assisting with the admission of a client who has leukemia. Which of the following transmission precautions should the nurse implement?

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

A nurse is assisting with the admission of a client who has meningococcal pneumonia. Which of the following isolation precautions should the nurse initiate?

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following items should the nurse wear?

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?