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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Applying powder to sensitive skin areas can cause dryness and irritation, exacerbating SLE symptoms. Powders can also block pores, increasing the risk of skin infections.
Choice B rationale
Using a strong protein shampoo is not relevant to managing SLE. It won't address the photosensitivity or skin issues commonly associated with SLE.
Choice C rationale
Sun protection is crucial for SLE patients due to photosensitivity. UV exposure can trigger flare-ups, making a sun-blocking agent with SPF 30 or higher essential for skin protection.
Choice D rationale
Moisturizing lotions help prevent dryness and protect the skin barrier, which is important in SLE management. Avoiding them can lead to skin complications.

A. Resistance to flow of IV fluid. B. Burning or pain, swelling, or redness at the site. C. Reporting anxiety and depression. D. Report of nausea throughout the infusion and vomiting once. E. Absence of blood return from the IV catheter.

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

Explanation

Choice A rationale
Resistance to the flow of IV fluid may indicate infiltration or extravasation, where the medication leaks into surrounding tissues, necessitating stopping the infusion.
Choice B rationale
Burning or pain, swelling, or redness at the site are signs of extravasation, which is a serious complication of vincristine administration and requires immediate action.
Choice C rationale
Reporting anxiety and depression are not directly related to vincristine infusion site complications. These are more systemic effects and do not indicate the need to stop the infusion immediately.
Choice D rationale
Nausea and vomiting are common side effects of vincristine but do not indicate a problem with the IV line itself, so they do not require stopping the infusion.
Choice E rationale
Absence of blood return from the IV catheter may indicate that the catheter is not in the vein properly, which requires stopping the infusion to prevent tissue damage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse in the emergency department is monitoring a client who is receiving vincristine through a peripheral line. The nurse should monitor the client for which of the following complications indicating the need to stop the infusion? (Select all that apply.)

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

Explanation

A nurse is teaching a client who has a new prescription for prednisone to treat acute kidney rejection. The nurse should inform the client that which of the following is a therapeutic effect of this medication?

A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

A nurse is evaluating a client's laboratory results. The nurse should recognize that an increase in the client's prostate specific antigen (PSA) laboratory value is indicative of which of the following diagnoses?

A nurse is teaching a client who has stage IV pancreatic cancer about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

A nurse is preparing a client for a radiation treatment who is postoperative following a mastectomy.The nurse should inform the client to expect which of the following adverse effects from the radiation treatment?

A nurse is caring for a client who has a new diagnosis of systemic lupus erythematosus (SLE) and asks where this disease originates within the body. The nurse should tell the client that SLE originates in which of the following locations in the body?

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?