An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4" F (40.8" C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

Give acetaminophen (Tylenol) rectal suppository.

Provide O2 at 2 L/min with a nasal cannula.

Apply wet sheets and a fan to the patient

Start lactated Ringer's solution at 1000 mL/hr

Answer and Explanation

The Correct Answer is C

A. Giving acetaminophen is appropriate for fever reduction but does not address the hypotension and potential dehydration in this scenario.
B. Providing oxygen is important, but the patient's hypotension requires fluid resuscitation as the initial priority.
C. Applying wet sheets and a fan are immediate actions focused on rapid cooling. The priority is to lower the body temperature as quickly as possible to prevent organ damage.
D. Starting lactated Ringer's solution at a high rate is crucial to address hypovolemia and to cool the patient effectively through intravenous hydration but should be done after cooling the patient using a wet sheet.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

This prescription helps maintain oral hygiene and comfort, which is important during chemotherapy to prevent and manage mucositis.
Routine daily temperature checks may not be necessary unless there are specific concerns about infection or fever.
Placing the client in a private room can reduce the risk of infection, which is crucial due to the client's immunocompromised state from chemotherapy.
Unless there is a specific medical indication (e.g., urinary retention), inserting an indwelling urinary catheter increases the risk of infection, which should be minimized in an immunocompromised client.
Droplet precautions are typically used for respiratory infections transmitted by large droplets. Lung cancer itself does not typically require droplet precautions unless there is an active respiratory infection.

A. A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min B. A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky. C. An unconscious adult client who has a large head wound with gray matter exposed; absent respirations D. An unconscious 6-month-old infant with no respirations, no visible injuries

Correct Answer is A

Explanation

A. In mass casualty triage, priority is given to clients who are salvageable with immediate intervention. This client is conscious (airway is intact) but has respiratory distress (RR > 30/min), suggesting potential inhalation injury or early shock. Prompt treatment can be life-saving.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C.Unconscious adult with large head wound and exposed gray matter, absent respirationsis unsalvageable; in triage terms, this client would be black tag (expectant). Immediate care will not change survival.

D.Unconscious 6-month-old infant with no respirations, no visible injuriesis also considered unsalvageable without immediate resuscitation; triage prioritizes those with highest likelihood of survival.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4" F (40.8" C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of lung cancer. Exhibits For each potential provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

Correct Answer is A

Explanation

A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply.)

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?

A nurse is caring for a client who is admitted to the emergency department for fatigue. Exhibits Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?