A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

Remove excess clothing from the client.

Restrict the client's fluid intake.

Place a warming blanket over the client.

increase the temperature in the client's room.

Answer and Explanation

The Correct Answer is A

A: This helps reduce body temperature by increasing heat loss through evaporation and radiation. Removing layers allows the body’s natural cooling mechanisms to function more effectively.
B: This would be inappropriate because adequate hydration is crucial for a febrile patient to help regulate body temperature and prevent dehydration.
C: This would be counterproductive as it would add heat to the body instead of helping to lower the body temperature.
D: Increasing the room temperature would worsen the situation by making the environment warmer, which would hinder the body's ability to cool down naturally.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A: Due to age-related reductions in gastrointestinal muscle efficiency, which slows the digestive process and can lead to increased water absorption from stool.
B: Overstates the issue, not all elderly patients experience difficulties, and it does not account for individual variability or other influencing factors like diet and medication.
C: Misrepresents the frequency and reasons for laxative use among the elderly, not all of whom misuse these medications.
D: While changes in rectal sphincter elasticity can affect some elderly individuals, it is less commonly a direct cause of constipation compared to decreased peristalsis.

A. Decreased plasma volume. B. Problems with the heart's electrical conduction system. C. Shock. D. A blockage of blood flow.

Correct Answer is D

Explanation

A. Decreased plasma volume might cause overall weak pulses but would unlikely cause an absent pulse specifically localized in one or more extremities. Decreased plasma volume generally affects circulation systemically, not selectively in certain limbs.
B. Problems with the heart's electrical conduction system primarily affect the rhythm and rate of the heart but do not directly cause absent pulses in extremities. These issues lead to irregular or abnormal heartbeats, not localized absence of pulses.
C. Shock can result in weak or thready pulses due to poor blood flow, but shock alone would not typically cause a pulse to be completely absent in one extremity while present in others. Shock affects the circulatory system as a whole.

D. A blockage of blood flow is the most likely cause of an absent pulse in one or more extremities. This could be due to atherosclerosis, embolism, or thrombosis, which can obstruct blood flow in specific areas, leading to no detectable pulse in those extremities.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has an oral temperature of 39.5°C (103.1°F). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

Correct Answer is A

Explanation

A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates

Correct Answer is D

Explanation

During auscultation, the nurse hears fine rales in the patient's lower lobes bilaterally. Fine rales are described as

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

The nurse gives the patient the following instructions: "Focus on the far wall and now focus on my pen." The nurse is assessing the

While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

When performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that