A nurse is assessing a client's body temperature and obtains a reading of 102°F (38.9°C). What action should the nurse take?
Administer antipyretic medication.
Document the temperature and continue monitoring.
Apply cool compresses to the client's forehead.
Notify the healthcare provider immediately.
The Correct Answer is B
Answer: b. Document the temperature and continue monitoring. Explanation: A temperature reading of 102°F (38.9°C) indicates a fever but does not require immediate intervention unless accompanied by other significant symptoms or in certain high-risk populations. The nurse should document the temperature and continue monitoring the client's condition.
a. Administering antipyretic medication may be appropriate based on the client's symptoms and healthcare provider's orders, but it is not the immediate action for a single temperature reading of 102°F.
c. Applying cool compresses can provide comfort to the client but does not address the underlying cause of the fever.
d. Notifying the healthcare provider immediately is not necessary based solely on a temperature reading of 102°F without other significant symptoms or concerns.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: c. 20 seconds
Explanation: To obtain an accurate reading using an electronic thermometer, the nurse should leave the thermometer in place for approximately 20 seconds or as recommended by the manufacturer's instructions.
a. 5 seconds is typically not sufficient to obtain an accurate reading with an electronic thermometer.
b. 10 seconds may be sufficient for certain electronic thermometers, but 20 seconds is generally recommended for accuracy.
d. 1 minute is longer than necessary for most electronic thermometers and may not provide any additional benefit in terms of accuracy.
Correct Answer is B
Explanation
Answer: b. Document the temperature and continue monitoring. Explanation: A temperature reading of 102°F (38.9°C) indicates a fever but does not require immediate intervention unless accompanied by other significant symptoms or in certain high-risk populations. The nurse should document the temperature and continue monitoring the client's condition.
a. Administering antipyretic medication may be appropriate based on the client's symptoms and healthcare provider's orders, but it is not the immediate action for a single temperature reading of 102°F.
c. Applying cool compresses can provide comfort to the client but does not address the underlying cause of the fever.
d. Notifying the healthcare provider immediately is not necessary based solely on a temperature reading of 102°F without other significant symptoms or concerns.
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