A nurse at an urgent care clinic is contributing to the plan of care for a client following a near drowning while attempting to walk across a frozen pond. Which of the following interventions should the nurse recommend?
Replace wet clothing with warmed blankets.
Use an axillary thermometer to monitor the client's temperature.
Assist the client to perform range-of-motion exercises.
Administer an antihypertensive medication.
The Correct Answer is A
A. "Replace wet clothing with warmed blankets.": Hypothermia is a significant concern after near-drowning in cold conditions. Replacing wet clothing with warmed blankets helps stabilize body temperature.
B. "Use an axillary thermometer to monitor the client's temperature.": Axillary thermometers are not accurate for hypothermic clients. Core temperature monitoring is more reliable.
C. "Assist the client to perform range-of-motion exercises.": This is not a priority in acute care following hypothermia or near-drowning.
D. "Administer an antihypertensive medication.": Hypertension is not the focus unless specific cardiovascular conditions are present.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will lie down for 30 minutes after each meal.": Lying down after meals increases reflux risk; clients should remain upright for 2–3 hours after eating.
B. "I will increase vitamin C intake by drinking orange juice.": Citrus juices are acidic and can aggravate GERD symptoms.
C. "I will sleep flat on my back at night.": Sleeping flat increases reflux; elevating the head of the bed is recommended.
D. "I will eat six small meals each day.": Smaller, more frequent meals reduce gastric distension and lower the risk of reflux.
Correct Answer is C
Explanation
A. "It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.
B. "I will perform breast exams every other month": BSE should be done monthly to detect any changes early.
C. "It is common for one breast to be larger than the other." Slight asymmetry between breasts is normal and not a cause for concern unless there is a sudden change.
D. "I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.
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