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","B","C","D"]
Explanation
Choice A rationale
Wearing multiple layers of clothing helps to trap body heat, preventing hypothermia.
Choice B rationale
Drinking warm fluids from a thermos helps maintain body temperature by providing warmth.
Choice C rationale
Wearing gloves and earmuffs prevents heat loss from extremities, which is essential in preventing hypothermia.
Choice D rationale
Wearing a loose-fitting hat prevents heat loss from the head, which is a significant source of body heat loss.
Correct Answer is D
Explanation
Choice A rationale
Avoiding crowds is to prevent the client from getting infections due to immunosuppression, not to prevent spreading infection to others, thus an incorrect rationale.
Choice B rationale:
Running a toothbrush through a dishwasher may seem hygienic but is generally unnecessary. More effective measures are needed to ensure oral hygiene without excessive sterilization.
Choice C rationale
Antiemetics are typically taken prior to or at the first sign of nausea during chemotherapy, not after the infusion is complete, so this statement is incorrect regarding the timing of antiemetic use.
Choice D rationale
Calling the doctor for unusual menstrual bleeding is crucial as it can indicate thrombocytopenia, a potential side effect of chemotherapy, reflecting the client's correct understanding.
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