what is the nurses priority action when a patient has a fever

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. What is the priority action for a patient with a fever?

A. Administer an antipyretic medication as prescribed.
B. Assess the patient's temperature regularly.
C. Provide cooling measures such as a cool compress.
D. Provide the patient with blankets for comfort.

Correct answer: B

Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.

2. If a client refuses surgery, but the family insists, what should the nurse do in this situation?

A. Respect the family's decision and proceed with the surgery.
B. Respect the client's decision and notify the healthcare provider.
C. Try to mediate between the family and the client.
D. Encourage the client to follow their family's wishes.

Correct answer: B

Rationale: In this situation, the nurse should respect the client's decision and notify the healthcare provider. The client has the right to refuse treatment, and the nurse must advocate for the client's autonomy. Proceeding with the surgery against the client's wishes would violate their autonomy and ethical principles. Trying to mediate between the family and the client may be appropriate, but ultimately, the client's decision should be respected. Encouraging the client to follow their family's wishes disregards the client's autonomy and is not ethically appropriate.

3. A patient reports nausea and vomiting after chemotherapy. What is the nurse's priority action?

A. Administer an antiemetic as prescribed.
B. Encourage the patient to eat small, frequent meals.
C. Provide the patient with anti-nausea wristbands.
D. Encourage the patient to rest after eating.

Correct answer: A

Rationale: The correct answer is to administer an antiemetic as prescribed. Chemotherapy-induced nausea and vomiting can be distressing for patients. Administering an antiemetic helps alleviate these symptoms effectively. Choice B, encouraging the patient to eat small, frequent meals, may be helpful for other gastrointestinal issues but is not the priority when the patient is experiencing nausea and vomiting. Choice C, providing anti-nausea wristbands, may offer some relief but is not as direct and immediate as administering an antiemetic. Choice D, encouraging the patient to rest after eating, is not the priority in this situation where the focus should be on managing the nausea and vomiting.

4. A nurse at a provider's office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (SATA)

A. Top fruits with yogurt
B. Add cream to soups
C. Increase fluids during meals
D. Use milk instead of water in recipes

Correct answer: A

Rationale: Topping fruits with yogurt is the correct recommendation to increase calorie and protein intake for a client on chemotherapy who is losing weight. Yogurt is a good source of protein and adding it to fruits can provide additional calories as well. Choice B, adding cream to soups, may increase calorie intake but does not specifically address protein needs. Choice C, increasing fluids during meals, is important for hydration but does not directly address calorie and protein intake. Choice D, using milk instead of water in recipes, may increase calorie content but does not focus on increasing protein intake, which is essential for clients on chemotherapy.

5. What is the most important nursing intervention for a patient with diarrhea?

A. Encourage the patient to increase fluid intake.
B. Monitor the patient's skin integrity.
C. Check the patient's electrolyte levels.
D. Educate the patient about infection control measures.

Correct answer: B

Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.