On a hot humid day, a nurse is caring for a client who is confused and presents with these vital signs: temperature 104.1°F (40.1°C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mmHg.
What action would the nurse take to provide immediate appropriate care?
Encourage the client to drink cool water or sports drinks.
Administer acetaminophen 650 mg orally.
Start an intravenous line and infuse 0.9% saline solution.
Encourage rest and reassess in 15 minutes.
The Correct Answer is C
Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hyperpigmentation is a common manifestation of Addison's disease due to increased production of melanocyte-stimulating hormone along with adrenocorticotropic hormone (ACTH).
Choice B rationale
Purple striations are more characteristic of Cushing's syndrome, not Addison's disease; they result from prolonged exposure to high cortisol levels.
Choice C rationale
Intention tremors are not associated with Addison's disease; they are more commonly related to neurological conditions such as multiple sclerosis or cerebellar disorders.
Choice D rationale
Hirsutism is not typical of Addison's disease but is more related to conditions involving excess androgen production, such as polycystic ovary syndrome (PCOS).
Correct Answer is C
Explanation
Choice A rationale
Examining the client for hepatomegaly can be part of a broader assessment but does not directly address the fatigue related to chemotherapy, particularly cisplatin, which is known to cause bone marrow suppression.
Choice B rationale
Assessing for a hypersensitivity reaction is important during chemotherapy, but it does not specifically address the issue of fatigue, which is often related to blood cell counts.
Choice C rationale
Checking the results of the client's most recent CBC (complete blood count) is crucial because cisplatin can cause anemia, leukopenia, and thrombocytopenia, all of which can lead to significant fatigue.
Choice D rationale
Evaluating for hypercalcemia is not typically associated with cisplatin treatment; it is more relevant in malignancies associated with bone metastasis or overproduction of parathyroid hormone-related protein.
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