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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. "Trendelenburg with legs extended.": Trendelenburg increases pressure on the abdomen, worsening evisceration.
B. "Supine with knees flexed.": This position reduces abdominal tension, minimizing further protrusion of the contents and providing comfort until surgical intervention.
C. "Semi-Fowler's with legs extended.": This position does not adequately reduce abdominal tension.
D. "Left-lateral with knees flexed.": Lateral positions are not suitable because they do not address abdominal tension or allow easy surgical access.

A. Hct B. INR C. BUN D. LDL

Correct Answer is B

Explanation

A. Hct: Hematocrit measures red blood cell concentration but is not directly affected by warfarin therapy.
B. INR: The international normalized ratio (INR) is the key lab value to monitor in clients taking warfarin, as it reflects the drug’s effect on blood clotting and helps ensure the dose is therapeutic (target INR typically 2-3 for atrial fibrillation).
C. BUN: Blood urea nitrogen assesses kidney function and is unrelated to warfarin monitoring.
D. LDL: Low-density lipoprotein levels assess cardiovascular risk but are not affected by warfarin.

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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?

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