A nurse is caring for a client who has a temperature of 38.7° C (101.7° F). Which of the following nursing interventions is appropriate?

Keep the client's bed linens dry.

Apply an alcohol-water solution to the client's skin.

Encourage the client to drink 1,500 mL of fluid per day.

Apply ice packs to the groin.

Answer and Explanation

The Correct Answer is A

A.   Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens.
B.   Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever.

C.   Encouraging increased fluid intake is appropriate to promote hydration, but the specific amount should be individualized based on the client's condition and needs.
D.   Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.

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Correct Answer is D,A,B,C

Explanation

Correct order: D A B C

D. Ask about the type of tobacco product used.

A. Teach the client cessation strategies.

B. Develop a cessation plan with the client.

C. Assist the client in modifying the plan if necessary.

A. A client who has diminished vision ambulating in well-lit areas B. A client who received a diuretic 30 min ago C. A client who requires assistance with ambulation D. A client who had a tonic-clonic seizure 2 hr ago

Correct Answer is D

Explanation

A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

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A nurse is caring for a client who has a temperature of 38.7° C (101.7° F). Which of the following nursing interventions is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

42. A nurse is providing teaching to a client who uses tobacco products. (Move the steps that the nurse should take into the box on the right, placing them in the correct order of performance. All steps must be used.)

Correct Answer is D,A,B,C

Explanation

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Correct Answer is D

Explanation

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