A nurse is assessing a client's vital signs and notes a temperature of 38.5°C. What is the most appropriate nursing intervention?

Reassess the temperature after 2 hours.

Place the client in a warm blanket.

Administer antipyretics as prescribed.

Encourage the client to drink cold water.

Answer and Explanation

The Correct Answer is C

A. Reassessing the temperature after 2 hours delays intervention and may allow the fever to worsen or cause discomfort to the client.

B. Placing the client in a warm blanket would increase body temperature further and is inappropriate when the client is febrile.

C. Administering antipyretics as prescribed is the most appropriate intervention to help reduce fever, relieve discomfort, and prevent complications associated with elevated body temperature, such as dehydration or tachycardia.

D. Encouraging the client to drink cold water may provide temporary relief, but it does not actively treat the fever or address the underlying cause.

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Correct Answer is C

Explanation

A. Requesting a prescription for oxygen administration is a current action or intervention and would be included in the recommendation component, not background.

B. Client-reported pain is part of the current assessment and should be included in the assessment section of the handoff report.

C. Background includes relevant history or context that helps the next caregiver understand the client’s situation. In this case, noting that the client broke their hip 24 hours ago due to a fall provides essential historical information for postoperative care.

D. Requests for changes in prescribed diet are current needs or interventions and belong in the recommendation or assessment components, not background.

A. Client reports dull, aching pain in lower right calf. B. Client's oral temperature is 38.4° C (101.2" F). C. Client reports nausea following administration of pain medication. D. Client has a raised, red rash on their upper back. E. Client reports the rash on their back is itchy

Correct Answer is ["A","C","E"]

Explanation

A. Client reports dull, aching pain in lower right calf is subjective because it is based on the client’s personal experience and cannot be directly observed or measured by the nurse.

B. Oral temperature is an objective measurement, obtained using a thermometer, and is not based on the client’s perception.

C. Client reports nausea following administration of pain medication is subjective, as it reflects the client’s personal symptom experience.

D. A raised, red rash is an observable, objective finding that the nurse can see and assess visually.

E. Client reports the rash is itchy is subjective because it is the client’s personal sensation and cannot be measured directly by the nurse.

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A nurse is assessing a client's vital signs and notes a temperature of 38.5°C. What is the most appropriate nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (1-SBSR-R) for a client postoperative a total hip placement. Which of the following information should be included in the background component?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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