A client is admitted to the emergency department with a body ...

[ereecah]

A client is admitted to the emergency department with a body temperature of 103 F. It is a hot and humid day, and the client works in a factory with no air conditioning. Which actions by the nurse are appropriate when providing care to this client?
 
  Select all that apply.
  A) Use warm blankets.
  B) Restrict fluids.
  C) Apply cool washcloths to the face and neck.
  D) Assess vital signs.
  E) Remove or loosen clothing around the neck and chest.

Question 2

A client is receiving care for an elevated body temperature. Which assessment findings indicate that care has been effective?
 
  Select all that apply.
  A) Urine output of 20 ml/hour
  B) Moist mucous membranes
  C) Heart rate of 120 beats per minute
  D) Good skin turgor
  E) Blood pressure of 118/68 mmHg

[AaaA]

Answer to Question 1

Answer: C, E

Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. The nurse can also reduce clothing and skin covering by loosening clothing around the neck and chest. Warm blankets and fluid restriction would keep the temperature elevated rather than helping to decrease it.. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.

Answer to Question 2

Answer: B, D

Evidence that interventions have been effective for a client with an elevated body temperature includes moist mucous membranes and good skin turgor. Urine output of 20 ml/hour indicates dehydration. Blood pressure of 118/68 mmHg is not an indication of the control of fever. A heart rate of 120 beats per minute could indicate dehydration.

[ereecah]

TYSM

[lcapri7]

Gracias!