A homeless man, who remains unconscious after having a generalized seizure while standing on the street median in the hot August weather, is transported to the emergency department (ED) with possible heat stroke. The nurse obtains IV access and vital signs indicate a core body temperature of 104.8°F (40.4° C). Which action should the nurse implement first?

Spray a mist of water on the face and direct airflow on client.

Assess for confusion or change in level of consciousness.

Encourage client to drink cool beverages without caffeine.

Obtain blood samples for serum electrolytes evaluation.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Spray a mist of water on the face and direct airflow on client: Rapid cooling is the priority in suspected heat stroke with a core temperature above 104°F. Evaporative cooling is an immediate, effective intervention to reduce body temperature and prevent organ damage.

B. Assess for confusion or change in level of consciousness: The client is already unconscious, indicating severe neurologic impairment. Further assessment can occur after initiating life-saving cooling measures.

C. Encourage client to drink cool beverages without caffeine: Oral fluids are contraindicated because the client is unconscious and at high risk for aspiration. Cooling must be achieved through external methods.

D. Obtain blood samples for serum electrolytes evaluation: Laboratory evaluation is important but should not delay immediate interventions aimed at rapidly lowering the client’s dangerously elevated body temperature.

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Correct Answer is D

Explanation

Rationale:
A. Keep the arm and shoulder of the affected side immobile at all times: Immobilization is not recommended. Early mobilization and gentle range-of-motion exercises help prevent stiffness, maintain circulation, and reduce the risk of complications like frozen shoulder.

B. Maintain the chest tube drainage system slightly above the chest level: The drainage system must be kept below the level of the chest to allow gravity drainage of blood and prevent backflow into the pleural space. Elevating it above chest level would be unsafe.

C. Ensure that there is no fluctuation in the water-seal chamber: Fluctuation (tidaling) in the water-seal chamber is expected and reflects normal intrathoracic pressure changes during respiration. Absence of fluctuation may indicate tube obstruction or lung re-expansion, which requires assessment.

D. Encourage the client to breathe deeply and cough at frequent intervals: Deep breathing and coughing prevent atelectasis, promote lung re-expansion, and help maintain adequate oxygenation after hemothorax. This is an essential nursing intervention for chest tube care.

A. Central venous pressure (CVP) of 18 cm H20. B. Oxygen saturation of 78% C. Distended neck veins. D. Elevated left atrial pressure.

Correct Answer is B

Explanation

Rationale:
A. Central venous pressure (CVP) of 18 cm H₂O: This value is above the reference range and can occur with right-sided heart strain in PE. While abnormal, it is not as immediately life-threatening as severe hypoxemia and may develop gradually as pressure builds.

B. Oxygen saturation of 78%: This indicates severe hypoxemia and impaired gas exchange caused by ventilation–perfusion mismatch in PE. Critically low oxygen levels can rapidly lead to respiratory failure, dysrhythmias, and cardiac arrest, requiring immediate provider notification.

C. Distended neck veins: This finding suggests increased right-sided venous pressure due to obstructed pulmonary circulation. Although concerning and consistent with PE, it reflects a secondary hemodynamic effect rather than an immediate threat to oxygenation.

D. Elevated left atrial pressure: Pulmonary embolism primarily affects the right side of the heart and pulmonary circulation. Elevated left atrial pressure is more commonly associated with left-sided heart failure, making it less directly relevant in acute PE.

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Naxlex Comprehensive Predictor Exams

Which intervention should the nurse include in the plan of care (POC) for a client who has a chest tube due to a hemothorax?

Correct Answer is D

Explanation

A client is admitted to the intensive care unit (ICU) with increasing shortness of breath due to a pulmonary embolism (PE). Which finding should the nurse immediately report to the healthcare provider (HCP)? Reference Range: Central venous pressure (CVP) [2 to 14 cm H2O]

Correct Answer is B

Explanation

The nurse is admitting a postoperative surgical client to the intensive care unit (ICU) and a ventilator is prescribed. While anticipating potential complications, which equipment should the nurse place at the client's bedside?

A client with a femoral arterial sheath is admitted to the cardiac care unit (CCU) after a percutaneous transluminal coronary angioplasty (PTCA). Which intervention should the nurse provide during the first hour of postoperative care?

The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?

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Patient Data Click to mark whether the nursing action is indicated, contraindicated, or non-urgent. Each row must have one option selected.

After seven days of mechanical ventilation, an older adult client is extubated and is now receiving 50% oxygen via face mask. The client has become anxious and is beginning to hyperventilate. Which intervention is most important for the nurse to implement?