A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?
A Encourage fluid intake of 2,500 mL/day.
B Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).
C Immerse the client in cold water.
D Assist the client to ambulate.
The Correct answer and Explanation is:
The correct answer is A: Encourage fluid intake of 2,500 mL/day.
Explanation:
When a client has a fever due to an infection, the primary goal of nursing care is to manage the fever and prevent complications. Fever increases the body’s metabolic rate, which in turn raises fluid loss through sweating, evaporation, and potentially increased respiratory rate. This fluid loss can lead to dehydration if not adequately addressed. Encouraging a fluid intake of 2,500 mL/day helps to ensure that the client remains hydrated, which is essential for several reasons:
- Hydration Maintains Physiological Functions: Adequate hydration is crucial for maintaining blood volume, circulation, and the delivery of oxygen and nutrients to tissues. It also aids in temperature regulation, as a well-hydrated body can more effectively dissipate heat through sweating and vasodilation.
- Supporting Immune Function: Proper hydration supports the immune system by promoting the efficient functioning of cells, including those involved in fighting infections. Additionally, fluids help to thin mucus and secretions, facilitating their clearance from the respiratory tract.
- Preventing Complications: Dehydration can lead to serious complications, such as electrolyte imbalances, hypotension, and renal dysfunction. By maintaining sufficient fluid intake, these risks are minimized.
Why Other Options Are Incorrect:
- B: Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F): This temperature range is too cold and can cause discomfort or shivering, which may raise the metabolic rate and worsen the fever. A more appropriate room temperature would be slightly cooler than normal (around 21°C to 23°C or 70°F to 73°F) to promote comfort without causing the body to generate additional heat.
- C: Immerse the client in cold water: This is not recommended as it can cause vasoconstriction, which traps heat in the core of the body, leading to a paradoxical increase in core temperature. Rapid cooling can also lead to shivering, further increasing metabolic heat production.
- D: Assist the client to ambulate: While mobility is generally encouraged for clients, ambulation should be limited if the client has a fever, as it can increase metabolic demands and exacerbate fatigue. The priority is rest and recovery.
In conclusion, encouraging adequate fluid intake is the most appropriate intervention for managing fever in a client with an infection. This approach not only supports physiological functions but also reduces the risk of complications associated with dehydration.