A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

Muscle strength

Urinary output

Pain sensation

Heart rhythm

Answer and Explanation

The Correct Answer is D

The correct answer is D. Heart rhythm. Hypothermia can cause cardiac dysrhythmias such as bradycardia, atrial fibrillation, and ventricular fibrillation, which can lead to cardiac arrest.

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Correct Answer is D

Explanation

The correct answer is D. The parent should apply pressure with gauze if they see bleeding from the circumcision site, as this can indicate a complication such as infection or dislodgement of the plastic ring. The other statements are incorrect because they can interfere with the healing process or cause harm to the infant. Applying antibiotic ointment can cause irritation or allergic reaction, applying a snug diaper can increase pressure and friction on the penis, and wiping away yellow crusts can remove healthy tissue or cause bleeding .

A. Call the supervisor to ask for another nurse. B. Remove the nurse from the client care area. C. Assign clients to the remaining staff. D. Document objective findings about the situation.

Correct Answer is B

Explanation

Explanation: The first action that the charge nurse should take is to remove the nurse from the client care area, as this will protect the clients from potential harm and prevent further impairment of the nurse. The charge nurse should then call the supervisor, assign clients to other staff members, and document objective findings about the situation.

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A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

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