The nurse visits the client in his home and finds him with a ...

[dbose]

The nurse visits the client in his home and finds him with a temperature of 100.2F oral. The nurse's priority action is to:
 
  1. Notify the physician that the client has a fever and obtain an order for antipyretics.
  2. Assess the client further to determine possible cause of the fever.
  3. Talk with the family members to get information about the client's condition.
  4. Obtain a rectal temperature for increased accuracy.

Question 2

The nurse is preparing to insert an IV in a client's cephalic vein. When the vein is accessed with a venous catheter, the nurse can feel a pop upon penetrating the:
 
  1. Tunica media.
  2. Tunica adventitia.
  3. Tunica intima.
  4. Valves.

[dpost18]

Answer to Question 1

2
Rationale: The nurse should assess the client before implementing any nursing care or notifying the physician. The reason for the temperature might not be immediately assessed but the physician will need the nurse to provide as much data as possible when notified.

Answer to Question 2

2
Rationale: The tunica media is the middle layer of a vein; this layer is composed of the muscle and elastic tissues that constrict and distend the vein.