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.
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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Related Questions
Correct Answer is C
Explanation
A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.
B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.
Correct Answer is D
Explanation
A. Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.
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