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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Flex his hips while pulling the client. The nurse and AP should use proper body mechanics when repositioning a client to prevent injury and promote comfort. Flexing the hips while pulling the client reduces strain on the back muscles and allows for greater leverage.
The nurse and AP should raise the bed to a comfortable working height, not lower it to the lowest position. The nurse and AP should stand on opposite sides of the bed near the client's hips, not shoulders. The nurse and AP should remove any pillows under or around the client before repositioning him.
Correct Answer is A
Explanation
The correct answer is A. The client should begin collecting urine after discarding the first morning void, which is not part of the 24-hr period. The client should avoid eating a protein-rich diet during the collection period, as this can affect the creatinine level. The client does not need to cleanse the perineal area with an antiseptic towel each time before voiding, as this is not necessary for a creatinine clearance test. The client does not need to record the blood glucose level each time they void, as this is not related to the creatinine clearance test.
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