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.

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Correct Answer is ["B","C","E"]

Explanation

A. Change in moles can indicate skin cancer.
B. Change in bowel pattern can be a sign of colorectal cancer.
C. A nonhealing sore can indicate skin cancer or other types of cancer that manifest as chronic wounds.
D. Bloating is less specific and may indicate various health conditions but are not typically primary signs of cancer.
E. Nagging cough is can be a sign of lung and/or throat cancer.

A. Send blood to the lab for a complete blood count. B. Finish the airway, breathing, circulation, disability survey. C. Assess further for a cause of the decreased circulation, D. Start normal saline fluid infusion with a large bore IV line.

Correct Answer is C

Explanation

A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.

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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?

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Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["B","C","E"]

Explanation

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Correct Answer is C

Explanation

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?

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