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 B
Explanation
A. Check the patient's apical rate to check for a pulse deficit. While an apical pulse assessment may be useful later, the priority in a sudden drop in blood pressure with signs of fainting is to ensure adequate circulation by checking a central pulse.
B. Immediately check the client's carotid pulse. A significant blood pressure drop (132/82 to 104/52), pale skin, and signs of fainting suggest possible shock or circulatory collapse. The carotid pulse should be checked immediately to assess perfusion.
C. Elevate the head of the patient's bed to at least 45 degrees. Raising the head of the bed could worsen hypotension and decrease blood flow to the brain, increasing the risk of syncope. The Trendelenburg position or lying flat may be more appropriate.
D. Report the findings to the health care provider immediately. While the provider should be notified, the priority action is to assess circulation by checking the carotid pulse first before escalating care.
Correct Answer is B
Explanation
A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.