A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and "feels uncomfortable." The nurse should:
1. Apply hot packs to the axilla and groin
2. Wrap the client's four extremities
3. Restrict oral fluid consumption
4. Apply a hypothermia mattress
ANS: 3
Wrapping the client's extremities has been recommended to reduce the incidence and intensity of shivering. Hot packs should not be applied to the client's axilla and groin. Fluids should not be restricted, but increased to replace fluids lost as a result of the fever. Hypothermia blankets may be used to reduce fever, but if the client is already shivering, a hypothermia blanket is not used, as further stimulation of shivering should be avoided.
You might also like to view...
The pathophysiology class is learning how microorganisms develop resistance to anti-infective drugs. What is one way the nursing students would learn that microorganisms develop resistance to anti-infective drugs?
A) By rearranging their deoxyribonucleic acid (DNA) to produce membranes that are permeable to the drug B) By producing an enzyme that stimulates the drug C) By changing the cellular membrane to allow the drug entry into the cell D) By altering binding sites on the membrane or ribosomes so that the drug cannot enter the cell
An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia?
A) The different leukemias all involve unregulated proliferation of white blood cells. B) The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. C) The different leukemias all result in a decrease in the production of white blood cells. D) The different leukemias all involve the development of cancer in the lymphatic system.
The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection?
a. Ventrogluteal b. Vastus lateralis c. Deltoid d. Dorsogluteal
A patient who is taking lithium shares with the nurse, "I'm planning to breast-feed my baby who is due to be born in 2 months.". Which statement shows the best understanding of the effect of lithium on breast-feeding?
a. "Your medication would be excreted in your breast milk, so let's discuss a safer option for your baby.". b. "Your medication will cause the breast milk to have an unpleasant taste and will likely cause your infant to be gassy.". c. "This medication will likely affect your ability to lactate, resulting in a marked decrease in breast milk production.". d. "This medication can cause extreme mood fluctuations, which can have a negative effect on your ability to produce breast milk.".