The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take?
a. Place the patient on oxygen.
b. Encourage the patient to cough.
c. Restrict the patient's fluid intake.
d. Increase the patient's metabolic rate.
ANS: A
Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever.
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