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 A
Explanation
A. Wait 30 minutes and take an oral temperature. Waiting 30 minutes ensures an accurate reading, as consuming hot or cold foods or drinks can alter oral temperature results.
B. Advise the patient to drink a glass of cold water. Drinking cold water could artificially lower the oral temperature, leading to an inaccurate measurement.
C. Take a rectal temperature. A rectal temperature is not necessary in this situation unless a core temperature is required for clinical reasons.
D. Take the oral temperature as planned. Taking the oral temperature immediately after hot soup can result in a falsely elevated reading, making it unreliable.
Correct Answer is D
Explanation
A. Temperature, pulse, respirations, BP. While these are standard vital signs, they do not include oxygen saturation or pain level, both of which are critical in a patient with chest pain.
B. Temperature, pulse, respirations, BP, pain. Pain is an essential assessment, especially for chest pain, but oxygen saturation should also be measured to assess for hypoxia, which can contribute to cardiac symptoms.
C. BP, respirations, temperature, pulse. This option omits both oxygen saturation and pain level, which are essential in evaluating cardiac and respiratory function in a patient presenting with chest pain.
D. Temperature, pulse, respirations, blood pressure, O2 sat, pain. This option includes all critical assessments for a patient with chest pain. Oxygen saturation helps assess respiratory and circulatory efficiency, and pain assessment is vital in determining the severity and possible cause of the chest pain.
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