The nurse observes that the client who has an infection and a fever is sweating profusely about 90 minutes after receiving aspirin. What is the nurse's best first action?
A. Notify the physician.
B. Take the client's pulse and blood pressure.
C. Change the client's damp clothing and bedding.
D. Document the observation as the only action.
B
When the client has a fever, sweating profusely after taking aspirin can lead to a fall in blood pressure (from vasodilation and fluid loss), followed by a return of the fever. This manifestation, although associated with a temporary reduction of fever, does not mean the infection is resolv-ing.
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A patient is prescribed regular doses of epinephrine. Which of the following nursing diagnoses is related to comfort and would be most appropriate for this patient?
A) Imbalanced Nutrition: Less Than Body Requirements B) Disturbed Sleep Pattern, Insomnia Related to CNS Excitation C) Disturbed Sensory Perception D) Ineffective Tissue Perfusion
A progressive wavelike movement that occurs involuntarily in hollow tubes of the body, especially in the alimentary canal, to propel fluids, gas, and digestive substances forward is called
a. perisclerium. b. periprostatic. c. pleurolysis. d. peristalsis.
You are bathing a patient. You note a reddened area on the person's left shoulder. What should you do?
a. Massage the area during the back massage. b. Report the observation to the nurse. c. Apply powder to the site. d. Rub the area.
When ambulating a person, you stand:
a. In front of the person b. In back of the person c. To the side and slightly behind the person d. Where the person chooses