An unresponsive 78-year-old patient is admitted to the emergency department in a coma during a summer heat wave. The patient's core temperature is 106.2° F (41.2° C), blood pressure (BP) 86/52, and pulse 102. The nurse will plan to
apply wet sheets and a fan to the patient.
administer an acetaminophen (Tylenol) suppository.
start O2 at 6 L/min with a nasal cannula.
infuse lactated Ringer's solution at 1000 ml/hr.
The Correct Answer is A
Rationale:
A. The patient is experiencing classic heat stroke, indicated by a core temperature >104° F, hypotension, tachycardia, altered mental status, and age-related vulnerability. The priority intervention is rapid cooling to prevent organ damage and death. Applying wet sheets and a fan uses evaporative cooling, one of the most effective first-line measures for heat stroke. Immediate reduction of core temperature is essential.
B. Acetaminophen is ineffective for heat stroke because this condition is caused by external heat and thermoregulatory failure, not by pyrogen-mediated fever. Antipyretics do not lower core temperature in heat stroke.
C. Administering oxygen is supportive but is not the priority intervention. Oxygen may be needed if hypoxia develops, but rapid cooling takes precedence to prevent multi-organ failure.
D. Infusing lactated Ringer's can be necessary for hypotension and dehydration secondary to heat stroke, but rapid cooling is still the first priority. Excessively fast fluid infusion without monitoring could risk fluid overload, particularly in older adults with possible cardiac compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. The travel RN with 20 years of ICU experience who has been working in this ICU for 4 months is correct because this patient is critically ill with septic shock, requires continuous titration of a vasopressor, and is mechanically ventilated. Assigning an RN who is highly experienced in ICU care and familiar with the unit’s protocols and equipment ensures safe, competent management of complex interventions.
B. The newly graduated RN is incorrect because, despite completing orientation, she does not yet have the full critical thinking skills or experience needed to manage a patient with septic shock on a vasopressor and mechanical ventilation.
C. The experienced ICU RN called in on a day off is incorrect because fatigue and being called in unexpectedly may reduce alertness and effectiveness, which could compromise patient safety during a critical period.
D. The RN floated from PACU is incorrect because although PACU experience involves monitoring post-anesthesia patients, float nurses may not have the ICU-specific knowledge for managing septic shock, titrating vasopressors, or ventilator management.
Correct Answer is B
Explanation
Rationale:
A. 3.3 mL would deliver approximately 742 mg, which is far above the prescribed dose.
B. 1.1 mL provides approximately 250 mg, matching the provider’s order.
First, identify the ordered dose and the available concentration.
Ordered dose = 250 mg
Available concentration = 225 mg per 1 mL
Use the medication calculation formula:
Amount to administer (mL) = Ordered dose ÷ Concentration
250 mg ÷ 225 mg/mL = 1.11 mL, which rounds to 1.1 mL
C. 2.5 mL refers to the reconstitution volume, not the amount to administer.
D. 1 mL would deliver only 225 mg, which is less than the prescribed dos
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