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 A
Explanation
A reason: Yellow-green drainage on the surgical incision. Yellow-green drainage indicates a potential infection at the surgical site. Postoperative infections can complicate the healing process and require prompt medical intervention. This finding should be reported to the provider immediately.
B reason: Straw-colored urine from an indwelling urinary catheter. Straw-colored urine is a normal finding and does not indicate any complications related to the surgery. This choice does not require reporting to the provider as it is within the normal range of expected outcomes.
C reason: Blood pressure 112/76 mm Hg. This blood pressure reading is within the normal range and does not indicate any immediate postoperative complications. There is no need to report this finding as it does not suggest an adverse event.
D reason: Respiratory rate 18/min. A respiratory rate of 18 breaths per minute is within the normal range for adults and does not indicate any respiratory distress or other complications. This finding does not require reporting to the provider.
Correct Answer is C
Explanation
A reason:
Determining the time the client last received pain medication is important, but it should be done after assessing the current pain level. The nurse needs to know the severity of the pain to decide the next steps.
B reason:
Measuring the client's vital signs, including temperature, is also important, especially to rule out complications like infection. However, addressing the client's immediate pain should take priority to provide relief and then proceed with further assessments.
C reason:
Asking the client to rate her pain on a scale from 0 to 10 is correct. This provides a clear understanding of the pain's intensity, which is essential for determining the appropriate intervention. It allows the nurse to gauge the severity of the pain and respond accordingly.
D reason:
Repositioning the client and offering a back rub can help alleviate discomfort, but these actions should follow the pain assessment to ensure the interventions are appropriate based on the pain's severity and nature.
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