A nurse is caring for a client who is flushed and has a temperature of 38.7° C (101.7° F). Which of the following actions should the nurse take?
Remove blankets from the client.
Place cold packs on the client’s axillae.
Place a fan to blow air across the client.
Give the client an alcohol sponge bath.
The Correct Answer is A
Choice A reason: Removing blankets from the client is a good action to take. Blankets can trap heat and increase the body temperature. Removing them can help the client lose heat through radiation and convection.
Choice B reason: Placing cold packs on the client’s axillae is not a good action to take. Cold packs can cause vasoconstriction and shivering, which can increase the metabolic rate and the heat production. They can also cause discomfort and skin damage.
Choice C reason: Placing a fan to blow air across the client is not a good action to take. A fan can cause evaporation of sweat and moisture, which can lower the body temperature. However, it can also cause dehydration and electrolyte imbalance, which can worsen the client’s condition.
Choice D reason: Giving the client an alcohol sponge bath is not a good action to take. Alcohol can cause vasodilation and evaporation, which can lower the body temperature. However, it can also cause skin irritation, dryness, and absorption, which can lead to toxicity and complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: You do not need to have advance directives in place in order to refuse recommended treatment. Advance directives are legal documents that allow you to express your wishes for your health care in case you are unable to communicate or make decisions for yourself. You have the right to accept or refuse any treatment at any time, as long as you are competent and informed.
Choice B reason: An attorney is not needed in order for you to name a designee in your health care proxy. A health care proxy is a type of advance directive that allows you to appoint a person to make health care decisions for you if you are unable to do so. You can choose anyone you trust, such as a family member or a friend, as your designee. You do not need a lawyer to complete a health care proxy form, but you need to sign it in front of two witnesses.
Choice C reason: You can decline to have certain medical procedures performed in your living will. A living will is another type of advance directive that allows you to state your preferences for life-sustaining treatments, such as CPR, artificial ventilation, or feeding tubes. You can specify which treatments you want or do not want, and under what circumstances. You can also include your values and beliefs about your quality of life and end-of-life care.
Choice D reason: A living will cannot be an oral statement that you agree upon with your provider. A living will must be a written document that is signed by you and witnessed by two people. An oral statement may not be legally valid or enforceable, and it may not reflect your current wishes. You should review and update your living will periodically, and share it with your provider, your designee, and your family.
Correct Answer is A
Explanation
Choice A reason: Tightening the abdominal muscles is a good strategy to prevent back injury when lifting an object. The abdominal muscles support the spine and help maintain a neutral posture. Tightening them can reduce the stress on the back and prevent muscle strain or disc herniation.
Choice B reason: Bending at the waist is a bad strategy to prevent back injury when lifting an object. Bending at the waist can cause the spine to curve and lose its alignment. This can increase the pressure on the intervertebral discs and the spinal nerves, and lead to pain, inflammation, or nerve damage.
Choice C reason: Keeping legs straight is a bad strategy to prevent back injury when lifting an object. Keeping legs straight can limit the range of motion and the leverage of the lower body. This can force the back to do most of the work and increase the risk of injury. The nurse should bend the knees and hips and use the legs to lift the object.
Choice D reason: Holding the object away from the body is a bad strategy to prevent back injury when lifting an object. Holding the object away from the body can create a lever effect and increase the load on the back. This can cause the back muscles to overwork and fatigue, and lead to injury. The nurse should hold the object close to the body and keep it at the center of gravity.
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