Nokea
An individual accompanied by a friend was brought by ambulance to the emergency room. A nurse notes that the patient's skin is flushed and dry. Further assessment reveals the patient has not voided or ingested food or fluid in 18 hours. Temperature, pulse, blood pressure, and respirations are elevated, and sensorium alternates between clouded and clear. The physician diagnoses fever of unknown origin. Because the patient is restless and agitated, the plan is to make an effort to orally hydrate before attempting to start an IV line. The intervention most likely to be effective will be:
Correct Answer: D
Rationale: The correct answer is D: staying with the patient to ensure that a glass of liquid is ingested once every hour. This choice is the most effective intervention because the patient is in a state of restlessness and agitation, making it crucial to closely monitor fluid intake. By staying with the patient and ensuring regular liquid consumption, the nurse can help maintain hydration and potentially alleviate symptoms.
Choice A (placing a pitcher of water at the patient's bedside) may not be effective as the patient may not be able to independently drink the water when needed. Choice B (placing a "force fluids" sign at the head of the bed) might not address the patient's agitation and restlessness and could lead to increased anxiety. Choice C (asking the friend to give the patient a drink whenever the patient is alert) may not provide consistent monitoring and support needed for the patient's condition.
Therefore, choice D is the best option as it addresses the patient's need for hydration, agitation, and restlessness effectively