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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A reason:

Airborne isolation with an N95 mask and negative air pressure room is not necessary for symptoms typically associated with respiratory viruses like influenza.

B reason:

Droplet precautions with an N95 mask are not required unless there is a risk of aerosol-generating procedures. A surgical mask is typically sufficient.

C reason:

Contact precautions with a gown and gloves are used for infections spread by direct contact, not for respiratory infections.

D reason:

Droplet precautions with a surgical mask and keeping the door closed are correct. These precautions prevent the spread of infections that are transmitted through respiratory droplets.

A. Provide the client a sip of warm water, wait 5 minutes, and measure the temperature B. Document that the nurse was unable to measure the client's temperature C. Proceed to measure the oral temperature D. Wait 30 minutes and return to measure the oral temperature

Correct Answer is D

Explanation

A reason:

Providing a sip of warm water and waiting 5 minutes is not sufficient to ensure an accurate oral temperature reading. The temperature of the mouth needs to stabilize, which takes longer than 5 minutes.

B reason:

Documenting that the temperature could not be measured should be a last resort. The nurse should make an effort to obtain an accurate reading after an appropriate waiting period.

C reason:

Proceeding to measure the oral temperature immediately after consuming ice chips will likely yield an inaccurate reading, as the cold temperature can lower the reading artificially.

D reason:

Waiting 30 minutes before measuring the oral temperature is the correct action. This allows the oral cavity to return to its baseline temperature, ensuring a more accurate measurement.

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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?

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