A client with a body temperature of 104 °F is entering the flush phase of the fever. Which actions by the nurse are appropriate when providing care?
Select all that apply.
A) Restrict fluids.
B) Cover the client with a light sheet.
C) Monitor intake and output.
D) Cover the client with warm blankets.
E) Provide warmed intravenous fluids.
Answer: B, C
During the flush phase of a fever, the client's body is attempting to adjust the temperature set-point lower. Nursing measures are implemented in order to increase the body's heat loss. Covering the client with a light sheet is the intervention to use at this time. The nurse should also monitor the client's intake and output. Warm blankets and warm intravenous fluids will increase the body's temperature. Restricting fluids could lead to dehydration and a higher body temperature.
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