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 B

Explanation

A reason:

A young adult in skeletal balanced suspension traction is at risk for skin breakdown due to immobility, but they are typically more resilient compared to older adults. Age and overall health are important factors in skin integrity.

B reason:

An older adult with a hip fracture and in Buck's traction is at greatest risk for skin breakdown. Older adults have thinner, more fragile skin, and are more prone to complications from immobility. Buck's traction also limits mobility, increasing the risk of pressure ulcers.

C reason:

An adolescent in a halo brace has a risk for skin breakdown, particularly around the pin sites and under the brace, but adolescents generally have better skin resilience and healing capacity compared to older adults.

D reason:

A middle adult with a fractured radius and an arm cast is at minimal risk for skin breakdown compared to the other scenarios. This situation typically allows for more mobility and less pressure on vulnerable skin areas.

A. Contact B. Airborne C. Neutropenic D. Droplet

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

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Explanation

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Explanation

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