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Patient Data

Exhibits

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

Apply warm blankets

Administer an antipyretic

Place ice packs around the client's head

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Microwave a pack of gauze and distribute across the body

Administer intravenous fluids with a rapid infuser

Use a fluid warmer for intravenous fluids

Answer and Explanation

Correct Answer : A,D,E,H

A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.

B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.

C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.

D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.

E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.

F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.

G. Administer intravenous fluids with a rapid infuser: A rapid infuser increases infusion speed, not temperature. If fluids are not warmed, this may worsen hypothermia.

H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.

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Correct Answer is A

Explanation

A. Maintain strict intake and output: In septic shock, monitoring fluid balance is critical because clients are at high risk for hypovolemia, organ dysfunction, and multi-organ failure. Accurate intake and output measurements guide fluid resuscitation and help evaluate response to therapy.

B. Monitor blood glucose level: Hyperglycemia can occur in sepsis and should be monitored, but it is secondary to maintaining adequate perfusion and fluid balance. Glucose monitoring supports overall care but is not the immediate priority in shock management.

C. Assess warmth of extremities: Extremity warmth or coolness provides information about perfusion and circulatory status but is observational. It does not actively intervene to reverse the pathophysiologic processes of septic shock.

D. Keep head of bed raised 45 degrees: Elevating the head of the bed may reduce aspiration risk, but it does not address the urgent need to manage hypoperfusion, organ perfusion, and fluid status in septic shock.

A. Wear closed-toe shoes that are comfortable and fit well. B. Check blood sugar levels every four to six hours every day. C. Restrict alcoholic beverages to no more than 1 to 2 per week. D. Obtain an A1C blood test every year to monitor glucose control.

Correct Answer is A

Explanation

A. Wear closed-toe shoes that are comfortable and fit well: Proper footwear is essential to prevent foot injuries, ulcers, and infections in clients with diabetes, especially because neuropathy can reduce sensation. This response indicates understanding of a key self-care measure.

B. Check blood sugar levels every four to six hours every day: Blood glucose monitoring frequency should be individualized based on treatment regimen, activity, and glycemic control. A blanket schedule every four to six hours may not be appropriate for all clients.

C. Restrict alcoholic beverages to no more than 1 to 2 per week: Alcohol guidelines should be individualized, and alcohol can affect blood glucose unpredictably. Limiting intake is important, but this statement alone does not fully reflect diabetes management understanding.

D. Obtain an A1C blood test every year to monitor glucose control: The recommended frequency for A1C testing is usually every 3 months when starting treatment or if therapy changes, and every 6 months for stable control.

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Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

Correct Answer is A

Explanation

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Patient Data

Exhibits

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