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 A

Explanation

A) The client should hold the cane on the unaffected side to provide support for the affected side, which is weaker. Holding the cane on the affected side does not offer the necessary support and balance needed during ambulation, indicating a need for further teaching.
B) Keeping two points of support on the ground, such as one foot and the cane or both feet, is a safe practice that ensures stability while ambulating, so no further teaching is necessary for this action.
C) Advancing the cane before moving the unaffected leg is the correct technique. The cane should be moved first, followed by the affected leg, and then the unaffected leg, to maintain balance and support.
D) Supporting weight on both legs when moving the cane forward is appropriate as it provides a stable base and prevents the client from falling, indicating that the client understands the correct use of the cane.

A. Position the client for secretion drainage by gravity. B. Schedule postural drainage following meals. C. Give the client a bronchodilator immediately after the procedure. D. Instruct the client regarding the importance of fluid restrictions.

Correct Answer is A

Explanation

A. Positioning the client for secretion drainage by gravity is a key component of postural drainage to facilitate the removal of respiratory secretions.
B. Postural drainage is typically done before meals to avoid potential nausea during the procedure.
C. Bronchodilators are often administered before postural drainage to open the airways and improve the effectiveness of the procedure.
D. Encouraging fluid intake is important to help thin respiratory secretions and promote their removal during postural drainage. Fluid restrictions are not typically indicated in this context.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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