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 A

Explanation

A. "He is allergic to sulfa." Communicating a client’s allergies during transfer is critical to ensure patient safety and prevent adverse reactions. This information directly impacts medication administration and care planning on the receiving unit, making it essential to include in the transfer report.

B. "His partner has been visiting." While family involvement can be helpful, details about visitors are generally less urgent and not typically necessary in a transfer report unless they directly affect the client’s care or safety.

C. "He appears anxious about the transfer." Emotional status is important but is secondary to clinical information. If anxiety significantly affects the client’s care or safety, it might be mentioned, but it is not a priority in a transfer report focused on immediate clinical needs.

D. "He is voiding adequately." Although voiding status is relevant to some clients’ care, it is less critical than allergy information unless the client has a specific condition affecting urinary function that requires close monitoring. The allergy detail remains a higher priority in transfer communication.

A. Increase in protein requirements B. Increase in fluid requirements C. Decrease in vitamin intake D. Decrease in muscle mass

Correct Answer is D

Explanation

A. Increase in protein requirements: Protein needs may slightly increase with age to maintain muscle mass, but this does not directly cause weight gain. Instead, inadequate protein may contribute to muscle loss.

B. Increase in fluid requirements: Older adults typically have decreased thirst sensation, not increased fluid needs. Weight gain is not directly linked to hydration needs but more to energy balance.

C. Decrease in vitamin intake: While older adults may have reduced vitamin intake due to dietary changes, this affects micronutrient status rather than causing significant weight gain.

D. Decrease in muscle mass: Sarcopenia, the loss of muscle mass with aging, lowers basal metabolic rate. This decreases calorie expenditure, making it easier to gain weight even with unchanged food intake.

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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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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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