A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
Cover the adolescent with a thermal blanket.
Submerge the adolescent’s feet in ice water.
Initiate seizure precautions.
Administer oral acetaminophen.
The Correct Answer is C
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.
Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in a prone position can compromise respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
Correct Answer is D
Explanation
A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point. A noncoring needle also reduces the risk of infection and clotting.
Choice A is wrong because a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.
Choice B is wrong because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle.
It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.
Choice C is wrong because a 25-gauge needle is too small to access a port.
A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).
Normal ranges for ports vary depending on the type and size of the port, but generally they have a reservoir diameter of 1.5 to 2.5 cm, a catheter length of 40 to 60 cm, and a catheter diameter of 0.8 to 1.2 mm. Ports are usually flushed with saline or heparin solution every 4 to 6 weeks when not in use to prevent clotting.
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