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

Explanation

A. Taking salt tablets can lead to electrolyte imbalances and is not recommended for managing heat-related issues.
B. Drinking extra fluids helps prevent dehydration and is an effective measure to prevent heat-related illness.
C. Moving to a cool environment when feeling confused is important but is a reactive measure rather than preventive teaching.
D. Taking acetaminophen for feeling too warm does not address the underlying issue of heat-related illness and is not appropriate discharge teaching for this situation.

A. Apply calamine lotion to itching areas. B. Apply ice packs to both hands. C. Attempt to remove the patient's stings. D. Give diphenhydramine (Benadryl) 50 mg PO.

Correct Answer is D

Explanation

A. Applying calamine lotion can provide relief from itching but does not address potential complications such as swelling or allergic reactions.
B. Applying ice packs can help reduce swelling and pain, but it is not the priority action in this scenario.
C. Attempting to remove the patient's rings is crucial to prevent complications such as restricted blood flow due to swelling, which can be exacerbated by bee stings. However, this should be done after administering diphenhydramine.
D. The nurse should first administer diphenhydramine (Benadryl) 50 mg PO to counteract the effects of the bee venom and reduce the risk of anaphylaxis.

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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 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?

Correct Answer is B

Explanation

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?

Correct Answer is D

Explanation

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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?