A client with a body temperature of 104°F is entering the flush phase of the fever. To assist this client, the nurse will:
1. Cover the client with warm blankets.
2. Restrict fluids.
3. Cover the client with a light sheet.
4. Provide warmed intravenous fluids.
3. Cover the client with a light sheet.
Rationale:
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. Warm blankets and warm intravenous fluids will increase the body's temperature. Restricting fluids could lead to dehydration and a higher body temperature.
You might also like to view...
The nurse is reviewing care plans for patients. A priority nursing diagnosis for a patient just starting treatment with desmopressin (Stimate) would be
a. risk for injury. b. alteration in comfort. c. risk for excess fluid volume. d. deficient knowledge.
During an assessment 30 minutes following delivery, the nurse notes the fundus is firm, the perineal pad is saturated, and bleeding occurs in a trickle. What should the nurse suspect on the basis of these assessment findings?
a. Inverted uterus c. Retained placental fragments b. Lacerations d. Uterine atony
The adolescent client reports to the clinic nurse that her period is late, but that her home pregnancy test is negative. What should the nurse explain that these findings most likely indicate?
1. "This means you are not pregnant." 2. "You might be pregnant, but it might be too early for your home test to be accurate." 3. "We don't trust home tests. Come to the clinic for a blood test." 4. "Most people don't use the tests correctly. Did you read the instructions?"
The most common heart defect is:
1. ASD. 2. Patent Foramen Ovale (PFO). 3. Hypertrophic left heart syndrome. 4. Ventricular Septal Defect (VSD).