A nurse is caring for a client who has moderate hypothermia. Which of the following actions should the nurse take?

Place the client in a semi-Fowler's position,

Infuse warm IV fluids.

Assess the client's skin hourly when using a heating blanket.

Rewarm the client's extremities first.

Answer and Explanation

The Correct Answer is B

A) Place the client in a semi-Fowler's position:
While positioning can be beneficial for various conditions, it does not directly address the core issue of hypothermia. Rewarming the client effectively is the primary concern in hypothermia management.

B) Infuse warm IV fluids:
Administering warm IV fluids is a crucial intervention for moderate hypothermia as it helps increase the client's core body temperature more rapidly and effectively. This method ensures that the body's internal temperature is raised, which is vital for stabilizing the client.

C) Assess the client's skin hourly when using a heating blanket:
Monitoring the skin is important to prevent burns or skin damage from a heating blanket, but it is a supportive measure rather than a primary intervention. The key priority is to rewarm the client’s core.

D) Rewarm the client's extremities first:
Rewarming the extremities first can actually be harmful in hypothermia, as it can lead to a drop in core body temperature due to the return of cold blood from the periphery to the core (afterdrop). The focus should be on warming the core body first.

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Correct Answer is C

Explanation

A) "I should limit my weightlifting to three times per week.": While weightlifting can be beneficial for bone health, it is generally recommended to engage in weight-bearing and resistance exercises more frequently than three times a week for optimal bone density. The frequency and type of weightlifting should be tailored to individual needs and safety considerations.

B) "I can continue to horseback ride.": Horseback riding, especially if not done carefully, poses a risk of falls and fractures, which can be dangerous for individuals with osteoporosis. Activities with a higher risk of injury should be avoided or approached with caution.

C) "I will go walking with a friend around our neighborhood.": Walking is a low-impact, weight-bearing exercise that promotes bone health and mobility without high risk. It is a suitable and recommended activity for individuals with osteoporosis to help maintain bone density and prevent falls.

D) "I will join my brother at his community aerobics class.": Aerobics classes may involve high-impact exercises and movements that could increase the risk of fractures or falls in individuals with osteoporosis. Low-impact, bone-strengthening activities are generally recommended instead.

A. Keep client in semi-Fowler's position with right extremity flat. B. Manage pain with oral opioids every 6 hr. C. Check capillary refill hourly for the first 24 hr. D. Apply a compression dressing over the fracture site.

Correct Answer is D

Explanation

A) Keep client in semi-Fowler's position with right extremity flat: Keeping the client in a semi-Fowler's position with the extremity flat is not appropriate for managing a compound fracture. Elevating the affected limb, if possible, helps reduce swelling and pain, but the position should also consider overall stability and comfort.

B) Manage pain with oral opioids every 6 hr: Oral opioids are not the best choice for immediate pain management in an emergency setting, especially with a compound fracture. Intravenous pain medications are typically more effective for acute, severe pain in such situations and can provide quicker relief.

C) Check capillary refill hourly for the first 24 hr: Checking capillary refill is important to assess blood flow and perfusion, but hourly checks for 24 hours may not be necessary and can be overly frequent unless specific concerns arise. Monitoring should be based on clinical judgment and the client's condition.

D) Apply a compression dressing over the fracture site: Applying a compression dressing over the fracture site can help control bleeding and stabilize the area. Compound fractures involve an open wound, so controlling bleeding while minimizing the risk of infection is crucial. This intervention is essential in managing the initial trauma before more definitive surgical treatment.

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A nurse is caring for a client who has moderate hypothermia. Which of the following actions should the nurse take?

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