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: Pallor. Pallor refers to an abnormal paleness of the skin, which can be caused by various conditions such as anemia or shock. It is not related to heart rate.
B reason: Bradypnea. Bradypnea refers to an abnormally slow breathing rate. It is unrelated to heart rate and is not the correct term for describing an elevated heart rate.
C reason: Tachycardia. Tachycardia is the medical term for an abnormally fast heart rate, typically defined as a heart rate over 100 beats per minute. A heart rate of 115 falls into this category, making tachycardia the correct term.
D reason: Somnolence. Somnolence refers to a state of drowsiness or sleepiness. It is not related to heart rate and is not the appropriate term for describing an elevated heart rate.
Correct Answer is D
Explanation
A reason:
Maintaining the head of the bed in a flat position is incorrect. The head of the bed should be elevated to reduce the risk of aspiration.
B reason:
Mixing the three medications together is incorrect. Medications should be administered separately to avoid potential interactions and ensure the correct dosage of each medication.
C reason:
Diluting each medication with tap water is not recommended. Sterile water or the water specified in the medication guidelines should be used for dilution to maintain safety and prevent contamination.
D reason:
Flushing the NG feeding tube with 30 ml of water immediately following medication administration is correct. This ensures that the medications are cleared from the tube and helps prevent tube blockage.
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