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 ["2500"]
Explanation
Calculation:
To convert liters (L) to milliliters (mL), the conversion factor is:
1L = 1000mL
Given:
(2.5L×1000mL)/ 1L
= 2500mL
Thus, 2.5 L = 2500 mL.
Correct Answer is D
Explanation
A. Positional BP readings. While orthostatic blood pressure readings can assess for postural hypotension, there is no indication in the current vitals that the client is experiencing symptoms such as dizziness or syncope.
B. Carotid pulse and temperature. The client’s temperature is already documented as normal, and the carotid pulse is not needed when an irregular radial pulse has been noted. The apical pulse is the preferred method to assess for irregularities.
C. Full respiratory system assessment. The respiratory rate is within the normal range, with regular rhythm and normal depth, so a full respiratory assessment is not the immediate priority.
D. Apical pulse for one minute. An irregular radial pulse suggests the possibility of an arrhythmia. The apical pulse provides a more accurate assessment of heart rhythm and rate, ensuring a complete evaluation of the irregularity.
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