The nurse is caring for a patient who came to the emergency department with confusion and muscle cramps after working outside on a hot day. What is the priority action of the nurse?
Remove fans to prevent premature chilling.
Apply a hyperthermia blanket to lower temperature slowly.
Take the patient's temperature and vital signs.
Place the patient in a tub of iced water.
The Correct Answer is C
A. Remove fans to prevent premature chilling. While preventing rapid cooling is important in some cases, this action is not the priority. The patient’s symptoms suggest heat-related illness, which requires immediate assessment.
B. Apply a hyperthermia blanket to lower temperature slowly. Hyperthermia blankets are typically used in controlled environments for gradual cooling, but first, the patient’s temperature must be assessed to determine the severity of heat-related illness.
C. Take the patient's temperature and vital signs. Confusion and muscle cramps after working in heat suggest possible heat exhaustion or heatstroke, which can be life-threatening. Assessing temperature and vital signs is the priority to determine the severity and guide further treatment.
D. Place the patient in a tub of iced water. Ice water immersion is appropriate for severe heatstroke with a dangerously high core temperature, but cooling measures should only be initiated after confirming hyperthermia with a temperature assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["39.2"]
Explanation
Calculation:
The formula to convert Fahrenheit (°F) to Celsius (°C) is:
°C = (°F - 32) × 5/9
= (102.5 - 32) × 5/9
= (70.5) × 5/9
= 39.1666...
Rounding to the nearest tenth: 39.2 °C.
Therefore, 102.5 °F is equal to 39.2 °C.
Correct Answer is ["2"]
Explanation
Calculation:
Formula:
Capsulesperdose = Dose ordered/ Dose available
Given:
- Ordered dose = 2 mg
- Available dose = 1 mg per capsule
Capsulesperdose = 2mg/(1mg/capsule)
= 2 capsules
Thus, the nurse will administer 2 capsules per dose.
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