A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

Apply a heating pad to the client's neck.

Provide the client with dry clothing.

Offer the client a warm beverage.

Wrap the client in warm blankets.

Answer and Explanation

The Correct Answer is B

A. Apply a heating pad to the client's neck: Direct application of heat to the skin, especially in localized areas like the neck, can cause rapid vasodilation, leading to a dangerous drop in blood pressure and potential cardiac complications. It also increases the risk of burns on cold-numbed skin.

B. Provide the client with dry clothing: Removing wet clothing and replacing it with dry garments is the first priority in managing hypothermia. Wet clothes accelerate heat loss through conduction and evaporation. Stopping further heat loss is essential before attempting active rewarming.

C. Offer the client a warm beverage: While offering warm fluids can help increase core temperature and provide comfort, it is not the first priority. This intervention is more appropriate after ensuring the client is dry and wrapped in warm coverings.

D. Wrap the client in warm blankets: Wrapping the client in warm blankets is a critical intervention for passive external rewarming. However, it comes after the initial step of removing wet clothes to prevent ongoing heat loss. Blankets are most effective once the source of heat loss has been eliminated.

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Correct Answer is D

Explanation

A. Locks the wheelchair after transferring the client: Locking the wheelchair should occur before the transfer to prevent it from rolling during the movement. Locking it after transferring compromises client safety and increases the risk of falls or injury.

B. Places the bed in a high position before transferring the client to the wheelchair: The bed should be placed in the lowest safe position to allow the client’s feet to touch the floor and to ease the transition to a lower surface like a wheelchair. A high bed position creates an unsafe height differential.

C. Uses a narrow stance when assisting the client to the wheelchair: A wide stance provides a stronger, more stable base of support, which is essential for safe body mechanics during a transfer. A narrow stance can lead to imbalance and injury to the AP or client.

D. Positions the wheelchair parallel to the client's bed: Positioning the wheelchair parallel or at a slight angle to the bed allows for easier and safer transfers. This minimizes turning and supports a smoother pivot, reducing strain on both the client and caregiver.

A. "I will be told about alternative procedures before I'm asked to sign the consent form." B. "My nurse is responsible for obtaining informed consent." C. "Once I sign the consent form. I cannot change my mind about having the procedure." D. "The consent form will include the estimated time for my recovery from the procedure."

Correct Answer is A

Explanation

A. "I will be told about alternative procedures before I'm asked to sign the consent form." Understanding alternative options is a key component of informed consent. Clients must be informed about the risks, benefits, and alternatives to the proposed procedure so they can make a voluntary, educated decision.

B. "My nurse is responsible for obtaining informed consent." While nurses often witness the client’s signature and may provide teaching, the responsibility for obtaining informed consent legally lies with the provider performing the procedure, who must explain the details and answer questions.

C. "Once I sign the consent form, I cannot change my mind about having the procedure." Clients retain the right to withdraw consent at any time before the procedure begins. Signing the form does not waive this right, and they can refuse or delay the procedure if they choose.

D. "The consent form will include the estimated time for my recovery from the procedure." Recovery time is usually discussed during preoperative teaching but is not a required element of the consent form itself. The form primarily covers procedure details, risks, and alternatives.

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A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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