The nurse is caring for an unconscious patient who was just pulled from a freezing lake. What is the priority action of the nurse?
Have the patient drink hot liquids.
Bathe the patient to promote shivering
Remove restrictive items of clothing.
Wrap the patient in warmed blankets.
The Correct Answer is D
A. Have the patient drink hot liquids. An unconscious patient cannot safely swallow, and forcing fluids could lead to aspiration. Additionally, internal warming should be done cautiously to avoid complications like shock.
B. Bathe the patient to promote shivering. Shivering is the body’s natural response to generate heat, but bathing a hypothermic patient would further lower body temperature and worsen the condition.
C. Remove restrictive items of clothing. While removing wet or restrictive clothing is important, it is not the priority over actively warming the patient. Hypothermia management focuses on gradual rewarming.
D. Wrap the patient in warmed blankets. The priority in hypothermia is gradual external rewarming using warmed blankets to prevent further heat loss and safely increase body temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is C
Explanation
A. Instruct the client to report for weekly re-evaluations by the nurse. A pulse deficit indicates a difference between the apical and radial pulse rates, which may suggest cardiac dysfunction such as atrial fibrillation. This requires immediate evaluation, not just weekly monitoring.
B. Teach the client how to check pulses at home. While patient education is important, a pulse deficit is a clinical concern that should be addressed by a healthcare provider before self-monitoring is advised.
C. Report this finding to the physician. A pulse deficit may indicate arrhythmias or decreased cardiac output, requiring further evaluation and possible medical intervention. The physician should be informed promptly.
D. Document this finding. While documentation is necessary, the priority action is to report the pulse deficit to the physician so appropriate diagnostic tests and interventions can be initiated.
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