A client receiving chemotherapy develops a temperature of 102.2°F (39°C). The temperature 6 hours ago was 99.2°F (37.3°C). Which nursing intervention is the priority in this case?1 Assess the amount and color of urine; obtain a specimen for a urinalysis and culture.2 Administer the prescribed antipyretic and notify the primary health care provider of this change.3 Note the consistency of respiratory secretions and obtain a specimen for culture and sensitivity.4 Obtain the respirations, pulse, and blood pressure when rechecking the temperature in 1 hour.
The priority nursing intervention in this case would be Option 2: Administer the prescribed antipyretic and notify the primary health care provider of this change
The priority nursing intervention in this case would be Option 2: Administer the prescribed antipyretic and notify the primary health care provider of this change.
Having a temperature of 102.2°F (39°C) in a client receiving chemotherapy indicates a possible infection. This is a concern because chemotherapy suppresses the immune system, making the client more susceptible to infections. Administering an antipyretic, such as acetaminophen, can help reduce the client’s fever and provide some relief.
Additionally, it is important to notify the primary health care provider about this change in temperature. The healthcare provider needs to be informed of any change in the client’s condition, especially when the client’s immune system is already compromised due to chemotherapy. The healthcare provider may want to further evaluate the client for any signs of infection and may prescribe additional interventions, such as blood cultures or antibiotics.
While options 1, 3, and 4 are also important interventions, they are not the priority in this case. Assessing urine, respiratory secretions, and vital signs are all important aspects of monitoring a client’s overall health, but in this scenario, the priority is to address the elevated temperature and the potential infection.
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