A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?
Encourage fluid intake of 2,500 mL/day.
Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).
Immerse the client in cold water.
Assist the client to ambulate.
The Correct Answer is B
Choosing the best intervention for a client with fever due to infection:
The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:
a. Encourage fluid intake of 2,500 mL/day.
Rationale:
- Pros: Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
- Cons: While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.
b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).
Rationale:
- Cons: Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.
c. Immerse the client in cold water.
Rationale:
- Cons: Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.
d. Assist the client to ambulate.
Rationale:
- Cons: While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.
Therefore, the most appropriate intervention for a client with fever due to infection is:
a. Encourage fluid intake of 2,500 mL/day.
Remember:
- Individualize care based on the client's specific needs and preferences.
- Monitor the client's response to interventions and adjust as needed.
- Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.
Choice B rationale:
Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.
Choice C rationale:
The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.
Choice D rationale:
Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.
Correct Answer is B
Explanation
Choice A rationale:
1 cup of shredded lettuce is low in potassium and is not the best source of potassium for a client with heart failure. While vegetables like lettuce are generally healthy, they do not provide a significant amount of potassium.
Choice B rationale:
1 cup of cantaloupe is the best source of potassium among the given options. Cantaloupe is a fruit that contains a moderate amount of potassium. Including this fruit in the client's diet can help maintain a balanced potassium level, which is important for heart health.
Choice C rationale:
1 oz of tuna is a source of protein but is not particularly rich in potassium. While protein intake is important for overall health, other choices on the list provide more potassium, which is specifically needed for clients with heart failure.
Choice D rationale:
1 cup of raspberries is a good source of fiber and antioxidants, but it is not as rich in potassium as cantaloupe. While raspberries can be a healthy addition to the diet, they are not the best choice for addressing potassium needs in this scenario.
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