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Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Place ice packs around the client's head

Microwave a pack of gauze and distribute across the body

Administer intravenous fluids with a rapid infuser

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Use a fluid warmer for intravenous fluids

Apply warm blankets

Administer an antipyretic

Answer and Explanation

Correct Answer : C,D,E,F,G

A. Place ice packs around the client's head: This is a cooling intervention used for hyperthermia, not for treating hypothermia.
B. Microwave a pack of gauze and distribute across the body: This is unsafe, as microwaved materials can cause burns and do not provide effective heat distribution.
C. Administer intravenous fluids with a rapid infuser: Rapid infusion of warmed IV fluids can help restore core body temperature and prevent further hypothermia.
D. Check the temperature of the humidified oxygen attached to the ventilator: Cold or dry oxygen can contribute to heat loss, so ensuring that the humidified oxygen is warmed is an important step in maintaining normothermia.
E. Instill warm fluids in the nasogastric tube: Lavage with warm fluids via NG tube is an effective method of internal warming for hypothermic patients.
F. Use a fluid warmer for intravenous fluids: Warming IV fluids before administration prevents additional heat loss that could occur if room-temperature fluids are given.
G. Apply warm blankets: Passive external warming using warm blankets is an easy and effective intervention to increase body temperature.
H. Administer an antipyretic: Antipyretics (e.g., acetaminophen, ibuprofen) are used for fevers, not for hypothermia.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Identify information as late entry in the record. This action would only be necessary after the issue is resolved and documentation is restored.
B. Print electronic medical record (EMR) from backup server. While printing from the backup server is an option, notifying IT should be done first to address the root cause of the issue.
C. Notify Information services department of the situation. The IT department can assist in troubleshooting the issue and restoring the system to normal function.
D. Wait for notification that the system has been rebooted. It’s important to act proactively by notifying IT to help resolve the problem.

Correct Answer is []

Explanation

Potential Condition - Delirium:

The client exhibits confusion, difficulty with memory, and disorientation (e.g., not knowing what happened, asking about her husband, inability to recall medications), which are typical signs of delirium. Delirium is an acute change in mental status and is common in older adults post-surgery, particularly after trauma or hospitalization.

Actions to Take:

Reorient to environment: Reorientation helps to reduce confusion and anxiety. The client is unsure of her surroundings and what is happening, so gently reminding her of the situation can improve awareness and reduce distress.

Institute fall precautions: Delirium increases the risk of falls due to impaired cognitive function. Given that the client is ambulating with assistance and has difficulty understanding instructions (e.g., unsure of the call light), instituting fall precautions is essential to prevent injury.

Parameters to Monitor:

Nutritional intake/intake and output: The client had difficulty feeding herself and consumed only a small portion of the meal. Monitoring her nutritional intake is important for overall recovery and to prevent dehydration, particularly given her dry mucosa and skin tenting.

Intracranial pressure: Given the client's age, recent surgery, and possible trauma from the motor vehicle accident, monitoring intracranial pressure (via MRI order) is necessary to rule out any traumatic brain injury or worsening of symptoms, especially since she has periods of confusion and disorientation.

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Exhibits The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Correct Answer is C

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

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The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

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Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.