A nurse in the emergency room is caring for a client who is hypothermic and has slow breathing.
Which of the following actions should the nurse take?
Administer atropine to speed up respirations.
Administer heparin.
Remove wet clothing and apply warm blankets.
Try to maintain a normal room temperature.
The Correct Answer is C
Choice A rationale
Atropine is an anticholinergic medication that is used to increase heart rate in bradycardia, not to speed up respirations. It works by blocking the vagus nerve's action on the heart. Administering atropine to a hypothermic patient with slow breathing is inappropriate and could have adverse effects without addressing the underlying hypothermia. The standard of care focuses on rewarming the patient.
Choice B rationale
Heparin is an anticoagulant used to prevent blood clot formation. It has no role in the management of hypothermia or slow breathing. Administering heparin would be an incorrect intervention and could put the client at risk of bleeding, especially if they have other injuries. The primary goal is to rewarm the client.
Choice C rationale
Removing wet clothing is a critical first step as wetness increases heat loss through evaporation. Applying warm blankets, or using other rewarming methods, is the primary treatment for hypothermia to restore the client's core body temperature and improve physiological function, including respiratory rate.
Choice D rationale
Trying to maintain a normal room temperature is an insufficient measure for a hypothermic client. The client's core body temperature is already below normal (less than 95°F or 35°C), and they require active rewarming techniques to raise it. Simply maintaining the room temperature will not be effective and will delay proper treatment. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Hyperthermia is an abnormally high body temperature and is not a typical complication of submersion injury. Submersion injuries, particularly in cold water, more commonly lead to hypothermia, which is a dangerously low body temperature, due to rapid heat loss from the body.
Choice B rationale
Acute respiratory distress syndrome (ARDS) is a severe, life-threatening complication of submersion injury. Aspiration of water, even in small amounts, can damage the alveolar-capillary membrane, leading to pulmonary edema, impaired gas exchange, and a profound inflammatory response in the lungs, which is the hallmark of ARDS.
Choice C rationale
Hypertension, or high blood pressure, is not a typical complication of submersion injury. In fact, submersion can initially cause a vasovagal response leading to bradycardia and a drop in blood pressure, or subsequently lead to hypotension due to fluid shifts and systemic compromise.
Choice D rationale
While severe hypoxia from submersion can lead to cerebral edema and increased intracranial pressure, this is a consequence of the primary injury to the lungs, not a direct complication of the submersion itself. The most immediate and significant complication is the respiratory compromise that precedes other systemic effects.
Correct Answer is D
Explanation
Choice A rationale
Taking control and leading the group is a definition of leadership, not followership. Leadership involves influencing and guiding others toward a common goal, whereas followership involves supporting and contributing to the leader's vision and the group's objectives.
Choice B rationale
Working independently without collaboration is not an accurate description of followership. Effective followership is characterized by active engagement and collaboration with team members and leaders to achieve shared goals. It is a dynamic process, not a state of isolation.
Choice C rationale
Following directions without asking questions describes passive or obedient followership. This is not the optimal form of followership in nursing, which requires critical thinking and proactive engagement. Optimal followership involves questioning, providing feedback, and contributing to the team's success.
Choice D rationale
Optimal followership in nursing is an active and dynamic process where a nurse contributes their skills and knowledge in a collaborative manner to achieve shared goals. This involves critical thinking, providing constructive feedback, and working in synergy with other team members to enhance patient care and organizational outcomes.
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