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
Role agreement refers to the mutual understanding and consensus among individuals about their respective roles and responsibilities within a specific context, such as a healthcare team. It involves clarifying expectations and duties to ensure everyone is on the same page. This term does not describe the individual's psychological and professional process of adapting to a new position.
Choice B rationale
Role transition is the complex process of moving from one professional role to another. It involves significant changes in identity, expectations, knowledge, skills, and relationships. For Leonard, this involves shifting from the dependent, learning role of a student to the autonomous, accountable role of a registered nurse, which includes a period of adjustment and adaptation.
Choice C rationale
Role acceptance is the stage where an individual internalizes and fully embraces the new responsibilities and identity associated with a new role. While it is a part of the overall transition process, it does not encompass the entire journey of moving from one role to another. Role acceptance is a component of a successful transition, not the process itself.
Choice D rationale
Role recruitment is the process of attracting, screening, and selecting qualified candidates for a specific job. This term relates to the employer's activities in filling a position, not the individual's experience of changing roles. It is the beginning of the employment process, not the psychological or professional shift the individual undergoes.
Correct Answer is A
Explanation
Choice A rationale
The primary goal of mass-casualty triage is to achieve the greatest good for the greatest number of people. This principle, known as utilitarianism, dictates that medical resources and care are prioritized based on a patient's potential for survival. Patients with the highest likelihood of surviving are given precedence to optimize overall outcomes.
Choice B rationale
This is incorrect because providing care to the most critically injured patients first in a mass-casualty event would quickly deplete resources, potentially resulting in fewer overall survivors. This approach prioritizes immediate need over survival potential, which is contrary to the core principles of mass-casualty triage.
Choice C rationale
In a mass-casualty incident, resources are limited, and it is impossible to provide immediate advanced medical care to all patients. The goal is to efficiently allocate available resources, which often involves providing only basic life-saving interventions to a large number of people rather than comprehensive care to a few.
Choice D rationale
Allocating resources evenly among all patients in a mass-casualty event is inefficient and would lead to a poor outcome for a larger number of people. It would mean that those who could be saved with minimal intervention would not be prioritized, while those with non-survivable injuries would receive resources they cannot benefit from. *.
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