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Fundamentals
문제

A nurse is caring for a patient with a fever. Which nursing intervention should be implemented first to help reduce the patient's body temperature?

A 45-year-old patient admitted with pneumonia has developed a high fever of 102.8°F (39.3°C). The patient appears flushed, reports feeling hot and uncomfortable, and has been sweating profusely. Vital signs show: temperature 102.8°F (39.3°C), pulse 110 bpm, respirations 24/min, blood pressure 128/82 mmHg, and oxygen saturation 94% on room air.
해설
Removing excess blankets and clothing is the first intervention for hyperthermia as it promotes heat loss through radiation and convection without adverse effects. Other options like medication or ice packs require orders or can cause shivering.
같은 주제 다음 문제A nurse is assessing vital signs for a 68-year-old patient admitted with pneumonia and obt…

심화 해설


Clinical Reasoning and Priority Setting


This question tests your ability to prioritize nursing interventions for a febrile patient using a combination of clinical reasoning and fundamental thermoregulatory physiology. The patient's presentation—a fever of 102.8°F (39.3°C), tachycardia, tachypnea, and profuse diaphoresis—indicates that the body's "set point" in the hypothalamus has been elevated by pyrogens from the pneumonia, but the body is now actively attempting to dissipate heat. The profuse sweating and flushed skin are signs of cutaneous vasodilation, the body's primary physiological mechanism for heat loss.



The priority is to support, not counteract, these natural heat-loss mechanisms. The first and most logical step is to remove external barriers to heat dissipation. By removing blankets and excess clothing, you facilitate the evaporation of sweat and maximize radiant and convective heat loss from the skin's surface. This action directly aligns with the principles of passive cooling. A systematic review and meta-analysis on cooling methods highlights that while active cooling is crucial for severe hyperthermia and heatstroke (a core temperature above 40°C with central nervous system dysfunction), the initial management for a lower fever involves supporting the body's own thermoregulatory efforts . This patient's temperature of 39.3°C does not meet the criteria for heatstroke, which is a distinct pathophysiological state of thermoregulatory failure and systemic inflammation, not simply a high fever [1].



The other options are not the first priority. Administering an antipyretic like acetaminophen (Option 1) is a pharmacological intervention that resets the hypothalamic set point, but it takes time to take effect and does not address the immediate physical discomfort and impaired heat dissipation. Applying ice packs (Option 2) is a form of conductive cooling, but if applied while the patient is bundled in blankets, its effect is negated. Furthermore, ice packs can cause shivering, which generates metabolic heat and is counterproductive. Encouraging cold fluids (Option 4) is helpful for hydration but has a negligible direct effect on core temperature. The foundational, non-invasive, and immediate step to promote heat loss is to uncover the patient.


References (research sources)
  • [1]
    Heat-Related Illness and Heatstroke: A Narrative and Clinical Review for Emergency Clinicians.Research articleBridwell RE, Long B, Koyfman A, Lacy AJ. (2026) · DOI: 10.7759/cureus.107294

임상 시나리오

Clinical Practice Guide: Initial Fever Management
Assessment
  • Assess the patient's stage of fever: During the flush phase (defervescence), the skin is warm and diaphoretic, indicating the hypothalamic set point is resetting and heat loss mechanisms are active.
  • Obtain a full set of vital signs, including oxygen saturation, to monitor for compensatory tachycardia and tachypnea.
  • Evaluate for signs of thermoregulatory failure, such as altered mental status or hot, dry skin, which would indicate heatstroke and require immediate aggressive cooling.
Nursing Priorities
  1. Remove external barriers to heat loss: Take off blankets and excess clothing to promote evaporation of sweat and maximize radiant and convective cooling. This is the foundational first step.
  2. Promote airflow: Use a fan or open a window to enhance convective heat loss, but avoid directing cold air directly at the patient to prevent shivering.
  3. Administer antipyretics: Give acetaminophen or another ordered antipyretic after initiating non-pharmacological measures. These medications work by lowering the hypothalamic set point.
  4. Provide oral fluids: Encourage cool or room-temperature fluids to support hydration and replace losses from diaphoresis, aiding thermoregulation from the inside.
  5. Avoid aggressive external cooling: Do not apply ice packs or cold-water sponging as an initial intervention for a moderate fever. These can trigger shivering and peripheral vasoconstriction, which increase metabolic heat production and raise core temperature.
Patient Education
  • Explain that feeling hot and sweating are signs the body is working to lower the temperature.
  • Instruct the patient to wear light clothing and use only a sheet for cover if needed for comfort.
  • Reinforce the importance of fluid intake to prevent dehydration from sweating.

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