A nurse is caring for a client with a body temperature of 38°C (100.4°F). Which of the following interventions should the nurse prioritize?

Administer antipyretic medication as prescribed.

Encourage fluid intake to prevent dehydration.

Monitor vital signs every 4 hours.

Apply a cooling blanket to reduce fever.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.
Choice B rationale
Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.
Choice C rationale
Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.
Choice D rationale
Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.

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Correct Answer is A

Explanation

Choice A rationale
Sepsis is a systemic inflammatory response to infection, often characterized by fever (temperature of 38°C or higher) and tachycardia (heart rate of 120 beats per minute or higher). These symptoms indicate the body’s response to a severe infection.
Choice B rationale
Hypovolemic shock is caused by significant fluid loss, leading to decreased blood volume and perfusion. It typically presents with hypotension and tachycardia, but not necessarily fever.
Choice C rationale
Myocardial infarction (heart attack) is characterized by chest pain, shortness of breath, and other symptoms, but fever and tachycardia are not primary indicators.
Choice D rationale
Pulmonary embolism involves a blockage in the pulmonary arteries, leading to symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, but not typically fever.

A. Acute pancreatitis. B. Acute hematochezia. C. Left heart failure. D. Chronic hepatic failure.

Correct Answer is A

Explanation

Choice A rationale
Acute pancreatitis is characterized by severe epigastric pain and elevated levels of amylase and lipase. These enzymes are released into the bloodstream when the pancreas is inflamed, making acute pancreatitis the most likely diagnosis.
Choice B rationale
Acute hematochezia refers to the passage of fresh blood through the anus, usually in or with stools. It is not associated with elevated amylase and lipase levels or severe epigastric pain.
Choice C rationale
Left heart failure can cause symptoms such as shortness of breath and fluid retention, but it does not typically cause elevated amylase and lipase levels or severe epigastric pain.
Choice D rationale
Chronic hepatic failure involves long-term liver damage and may present with jaundice, ascites, and other symptoms. It is not associated with elevated amylase and lipase levels or severe epigastric pain.

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A nurse is caring for a client with a body temperature of 38°C (100.4°F). Which of the following interventions should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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