A nurse observes a client with an axillary temperature of 39°C (102.2°F). What is the priority nursing action?
Encourage fluid intake to prevent dehydration
Apply cold packs to reduce the client's temperature
Administer antipyretics as prescribed
Assess for signs of infection and notify the provider.
The Correct Answer is D
A. Encourage fluid intake to prevent dehydration: Promoting hydration supports thermoregulation and prevents fluid loss associated with fever. While important, it does not address the underlying cause or allow for immediate intervention if the fever indicates a serious infection.
B. Apply cold packs to reduce the client's temperature: External cooling measures can provide comfort but may trigger shivering, which can increase body temperature. Cold packs do not treat the underlying cause of fever and are supportive rather than primary interventions.
C. Administer antipyretics as prescribed: Antipyretics help lower body temperature and improve comfort. However, administering medication without assessing for the underlying cause of fever or notifying the provider may overlook a potentially serious infection.
D. Assess for signs of infection and notify the provider: A high fever can indicate an acute infection or other serious condition. Assessing for source, monitoring vital signs, and communicating findings to the healthcare provider ensures timely diagnosis and treatment, making this the priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Patient has chest pain. Needs to see a doctor.: This entry is vague and lacks essential subjective and objective data. It does not include the client’s own words, pain characteristics, or vital signs. Narrative charting requires detailed, specific, and measurable information.
B. Patient states, “I suddenly felt a sharp pain in my chest while gardening.” Rates pain as 6/10. No radiating pain reported. Blood pressure: 145/95 mm Hg. Heart rate: 100 beats/min, regular.: This entry includes subjective data in the client’s own words, objective assessment findings, and relevant vital signs. It clearly documents onset, quality, severity, and associated findings. This reflects accurate, complete, and legally sound narrative charting.
C. The patient was gardening when they got chest pain. Blood pressure high: This statement lacks specific pain description, numeric values, and patient-reported details. Terms such as “high” are non-measurable and imprecise. Incomplete data limits clinical usefulness.
D. The patient felt pain in the chest while in the garden. No further information provided.: This entry is incomplete and omits critical assessment details such as pain severity, vital signs, and associated symptoms. Narrative charting must provide sufficient information to guide clinical decision-making.
Correct Answer is B
Explanation
A. Introduce a blanket and stuffed animal to comfort the baby: Loose bedding and soft toys in the crib increase the risk of sudden infant death syndrome (SIDS) in newborns. This action is unsafe and not recommended for infants under 12 months.
B. Check for hunger, wet diaper, or cold and fix the issue quietly using minimal light and noise: Newborns wake frequently for basic needs. Addressing hunger, diaper changes, or temperature issues in a calm, quiet manner promotes restorative sleep and supports safety. Minimizing stimulation helps the baby return to sleep more easily.
C. Allow the baby to cry until they fall back asleep naturally: Letting a newborn “cry it out” is not appropriate at this age. Infants rely on caregivers for feeding, warmth, and comfort. Ignoring these needs can cause distress and disrupt healthy attachment.
D. Keep the baby awake during the day to reduce nighttime waking: Newborns have irregular sleep-wake cycles, and forcing wakefulness can lead to overtiredness, irritability, and difficulty feeding. Daytime sleep is essential for growth and development at this age.
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