A client with pneumonia has a temperature ranging between 101° and 102°F and periods of diaphoresis. Based on this information, which of the following nursing interventions would be a priority?
A. Maintain complete bed rest.
B. Administer oxygen therapy.
C. Provide frequent linen changes.
D. Provide fluid intake of 3 L/day.
Correct Answer: D. Provide fluid intake of 3 L/day
A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result of the fever and diaphoresis; this is a high-priority intervention. Force fluids to at least 3000 mL/day or as individually appropriate. Meets basic fluid needs, reducing risk of dehydration and to mobilize secretions, and promote expectoration.
Option A: Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate. Reduces stress and excess stimulation, promoting rest. Assist the patient to assume a comfortable position for rest and sleep.
Option B: The purpose of oxygen therapy is to maintain PaO2 above 60 mmHg. Oxygen is administered by the method that provides appropriate delivery within the patient’s tolerance. Note: Patients with underlying chronic lung diseases should be given oxygen cautiously.
Option C: Adjust and monitor environmental factors like room temperature and bed linens as indicated. Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate temperature of the patient.
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