A nurse is caring for a client who has a rectal temperature of 35°C (95°F). Which of the following actions should the nurse take?
Decrease the temperature in the client's room.
Request a prescription for an antipyretic medication.
Place a cooling fan near the client.
Place a warming blanket over the client.
The Correct Answer is D
A reason:
Decreasing the temperature in the client's room is incorrect. The client is already hypothermic and needs to be warmed, not further cooled.
B reason:
Requesting a prescription for an antipyretic medication is inappropriate. Antipyretics are used to lower fever, not to treat hypothermia.
C reason:
Placing a cooling fan near the client is incorrect and would exacerbate hypothermia.
D reason:
Placing a warming blanket over the client is correct. This action helps to gradually raise the client's body temperature to a safe level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A reason:
Contact precautions are used to prevent the spread of infections that are transmitted by direct or indirect contact with the patient or the patient's environment. These precautions are not specific to the needs of a client with a stem-cell transplant, who is more susceptible to infections due to a weakened immune system.
B reason:
Airborne precautions are used for infections that can be spread through the air over long distances, such as tuberculosis, measles, and chickenpox. This is not the primary concern for a client with a stem-cell transplant.
C reason:
Neutropenic precautions are correct. These are specific infection-control measures used to protect immunocompromised patients, such as those who have undergone an allogeneic hematopoietic stem-cell transplant. These precautions include measures to prevent infection from external sources because the patient’s immune system is significantly weakened.
D reason:
Droplet precautions are used to prevent the spread of infections that are transmitted through large respiratory droplets, such as influenza or meningitis. While important, these precautions are not tailored to the specific needs of a stem-cell transplant patient, who requires more stringent infection prevention measures.
Correct Answer is B
Explanation
A reason:
A blood pressure of 138/90 is elevated but not immediately life-threatening. It is important to monitor, but it is not the highest priority in this situation.
B reason:
A heart rate of 110 beats per minute is the most concerning and should be addressed first. Tachycardia can indicate pain, fever, or other underlying issues that need prompt attention.
C reason:
An O2 Sat of 95% is within normal limits and is not an immediate concern compared to the other vital signs presented.
D reason:
A temperature of 38°C indicates a fever, which needs to be addressed, but the elevated heart rate takes priority as it can have more immediate implications for the client's condition.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.