The nurse notes that a client's temperature has increased from 102°F (38.9°C) to 104°F (40°C). Which of the following is the most appropriate action for the nurse to take in this situation?
A) Consult the physician and give antipyretics to the client.
B) Provide physical cooling measures to the client.
C) Suggest that the client rest and take plenty of fluids.
D) Cover the client's head with a cap or a towel.
A
Feedback:
The nurse should consult the physician and give the client antipyretics. Antipyretics—drugs that reduce fever—such as Tylenol would be helpful in this case when the client's body temperature is between 102°F and 104°F (38.9 to 40°C). Physical cooling measures are used when the temperature exceeds this. When the temperature is below 102°F (38.9°C) and the client does not have any chronic medical condition, the nurse will ask the client to take plenty of fluids and rest, and will monitor the fever. The nurse will cover the client's head with a cap or a towel when the client has subnormal temperature, not when the client's temperature is above normal, since this measure helps to reduce heat loss.
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