A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?
Remove blankets from the client.
Place cold packs on the client’s axillae.
Place a fan to blow air across the client.
Give the client an alcohol sponge bath.
The Correct Answer is A
Choice A reason: Removing blankets from the client is a good action to take. Blankets can trap heat and increase the body temperature. Removing them can help the client lose heat through radiation and convection.
Choice B reason: Placing cold packs on the client’s axillae is not a good action to take. Cold packs can cause vasoconstriction and shivering, which can increase the metabolic rate and the heat production. They can also cause discomfort and skin damage.
Choice C reason: Placing a fan to blow air across the client is not a good action to take. A fan can cause evaporation of sweat and moisture, which can lower the body temperature. However, it can also cause dehydration and electrolyte imbalance, which can worsen the client’s condition.
Choice D reason: Giving the client an alcohol sponge bath is not a good action to take. Alcohol can cause vasodilation and evaporation, which can lower the body temperature. However, it can also cause skin irritation, dryness, and absorption, which can lead to toxicity and complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct answer because it distracts the client from the surroundings and could cause loss of balance or coordination.
Choice B reason: This is the correct answer because it enables the client to use the handrails as a support and reduces the stress on the arms and shoulders.
Choice C reason: This is not the correct answer because it creates an uneven distribution of weight and could cause instability or pain.
Choice D reason: This is not the correct answer because it requires the client to shift the body weight abruptly and could cause muscle strain or joint damage.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because women should continue to receive Papanicolaou tests until they are 65 years old or have had a hysterectomy.
Choice B reason: This is incorrect because perimenopause is the period of time before menopause when menstrual cycles become irregular and unpredictable.
Choice C reason: This is correct because headaches are a common symptom of perimenopause caused by hormonal fluctuations.
Choice D reason: This is incorrect because the best time to perform a breast self-examination is one week after the menstrual period, when the breasts are less tender and lumpy.
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