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 C

Explanation

A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.

C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.

A. Unsteady gait B. Report of short-term memory loss C. Hearing loss D. Report of frequent constipation

Correct Answer is A

Explanation

A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.

A. Ensuring safety and preventing falls is a priority.

B. Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C. Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D. Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.

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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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