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 C

Explanation

A. Keeping both arms below the level of the client's heart is not recommended for preventing lymphedema. The affected arm should be elevated when possible to reduce the risk of fluid accumulation.
B. Obtaining blood pressure readings on the affected arm is contraindicated because it can increase the risk of lymphedema.
C. Use the client's left arm to obtain blood samples: To prevent lymphedema, it's important to avoid using the affected arm (the right arm in this case) for invasive procedures like blood draws or blood pressure measurements, as this can increase the risk of lymphedema by promoting fluid retention.
D. Limiting range-of-motion exercises could impair recovery and muscle function. Early and gentle exercises should be encouraged to maintain mobility and avoid complications.

A. "It is common for the skin on my breasts to dimple." B. "I will perform breast exams every other month." C. "It is common for one breast to be larger than the other." D. "I will perform breast exams the day my period begins."

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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