A nurse is assigned a client who has been admitted with a high fever. Which nursing skill should the nurse use at the first contact with the client?

Assessment

Discharge planning

Counseling

No option provided.

Answer and Explanation

The Correct Answer is A

Choice A reason: Assessment is the first step in the nursing process, involving data collection on the client’s fever, vital signs, and symptoms. Fever increases metabolic rate and oxygen demand, potentially causing dehydration or tachycardia. Initial assessment identifies underlying causes (e.g., infection) and guides interventions, ensuring timely treatment to stabilize the client’s physiological status.

Choice B reason: Discharge planning is premature at first contact, as it occurs after assessing and stabilizing the client. Fever may indicate infection, requiring immediate evaluation of vital signs and symptoms to determine etiology. Planning discharge without understanding the client’s condition risks neglecting critical interventions, as fever can escalate systemic inflammatory responses if untreated.

Choice C reason: Counseling addresses emotional or educational needs but is inappropriate at first contact with a high fever. Fever, often from infection, activates inflammatory cytokines, increasing body temperature and heart rate. Assessment of physiological status takes precedence to identify causes and initiate treatment, ensuring patient safety before addressing psychological or educational needs.

Choice D reason: No fourth option was provided, but any non-assessment action would be less urgent. Fever signals a physiological disturbance, like infection, increasing metabolic demand and risking complications like dehydration. Initial assessment of vital signs, history, and symptoms is critical to identify the cause and guide interventions, ensuring effective management of the client’s condition.

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Correct Answer is B

Explanation

Choice A reason: Performing incentive spirometry 2 to 3 times every 1 to 2 hours is insufficient. Guidelines recommend 5-10 breaths per session, hourly if possible, to maximize lung expansion and prevent atelectasis. This frequency is too low to effectively improve ventilation, per postoperative pulmonary care protocols.

Choice B reason: Instructing the client to inhale slowly and deeply through the mouthpiece, without using the nose, ensures effective lung expansion. Slow inhalation raises the spirometer’s piston, opening alveoli, while nasal occlusion maximizes airflow. This technique prevents atelectasis, aligning with respiratory therapy and postoperative care guidelines.

Choice C reason: Inhaling normally before placing lips on the mouthpiece is incorrect, as incentive spirometry requires a maximal inspiratory effort, not a normal breath, to expand alveoli. Normal inhalation limits lung volume, reducing the device’s effectiveness in preventing postoperative atelectasis, per pulmonary rehabilitation principles.

Choice D reason: Holding the breath for 10 seconds after inhalation is excessive, as 3-5 seconds is sufficient to sustain alveolar expansion. A prolonged hold may cause discomfort or dizziness, reducing compliance. This instruction does not align with standard incentive spirometry protocols for postoperative lung function improvement.

A. Epiglottitis B. Bronchospasm C. Atelectasis D. Croup

Correct Answer is C

Explanation

Choice A reason: Epiglottitis is an acute bacterial infection causing epiglottal swelling, primarily in children, leading to airway obstruction. Postoperative pneumonia, caused by bacterial infection or aspiration, increases mucus production and impairs gas exchange but does not typically cause epiglottal inflammation. Assessing for epiglottitis is irrelevant, as it’s unrelated to pneumonia’s pathophysiology, which involves alveolar consolidation and impaired oxygenation.

Choice B reason: Bronchospasm involves airway constriction due to smooth muscle contraction, common in asthma or COPD. Postoperative pneumonia, characterized by alveolar infection and consolidation, reduces lung compliance and gas exchange but rarely causes bronchospasm. Assessing for bronchospasm is less relevant, as pneumonia primarily affects alveoli, not bronchial smooth muscle, making this an unlikely complication to monitor.

Choice C reason: Atelectasis, the collapse of alveoli, is a common postoperative complication, especially with pneumonia, due to mucus accumulation and reduced lung expansion. This impairs gas exchange, increasing hypoxia risk. Frequent assessment for atelectasis, indicated by diminished breath sounds and hypoxemia, is critical, as it exacerbates pneumonia’s effects on alveolar ventilation and requires interventions like deep breathing exercises.

Choice D reason: Croup is a viral infection causing laryngeal and tracheal swelling, primarily in children, leading to a barking cough. Postoperative pneumonia in adults involves bacterial alveolar infection, not upper airway inflammation. Assessing for croup is inappropriate, as it’s unrelated to pneumonia’s pathophysiology, which focuses on lower respiratory tract consolidation and impaired gas exchange.

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A nurse is assigned a client who has been admitted with a high fever. Which nursing skill should the nurse use at the first contact with the client?

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