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
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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Related Questions
Correct Answer is B
Explanation
A. Developing atrial fibrillation can be a complication of hypothermia, but rewarming is still necessary to address the underlying condition.
B. Active rewarming should be discontinued if the patient's core temperature reaches 94°F (34.4°C), as further active rewarming could lead to complications. It's important to transition to passive rewarming methods to allow the patient's temperature to normalize gradually.
C. A decrease in blood pressure may indicate hypovolemia or shock but does not necessarily require discontinuation of rewarming.
D. Shivering is a normal response during rewarming and does not indicate a need to discontinue rewarming efforts unless other complications arise.
Correct Answer is ["21"]
Explanation
Total volume in mL: 3000 mL
Time in hours: 24 hours
Total volume to be infused in minutes: We need to convert hours to minutes. There are 60 minutes in 1 hour. Therefore, total time in minutes = 24 hours * 60 minutes/hour = 1440 minutes
Drop factor: 10 gtt/mL
Rate in mL/min: We can divide the total volume (mL) by the total time (minutes) to find the flow rate in mL per minute. Rate (mL/min) = 3000 mL / 1440 minutes = 2.08 mL/min (rounded to two decimal places)
Rate in gtt/min: To find the rate in gtt/min, multiply the rate in mL/min by the drop factor. Rate (gtt/min) = 2.08 mL/min * 10 gtt/mL = 20.8 gtt/min
Rounding the answer to the nearest whole number: 20.8 gtt/min rounds off to the nearest whole number to 21 gtt/min.
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