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 A
Explanation
A. Carotid. The carotid arteries supply blood to the brain, and compressing both simultaneously can reduce cerebral blood flow, potentially causing dizziness, syncope, or loss of consciousness. Therefore, carotid pulses should be assessed one at a time.
B. Radial. The radial pulse can be safely assessed bilaterally at the same time since it does not affect central circulation or brain perfusion.
C. Brachial. The brachial pulse can also be assessed bilaterally without risk, as it does not impact blood flow to critical organs like the brain.
D. Femoral. The femoral pulse can be checked simultaneously on both sides to assess circulation and perfusion, especially in cases of suspected arterial insufficiency.
Correct Answer is A
Explanation
A. Body temperature follows a circadian rhythm, typically being lowest in the early morning (around 4–6 AM) and peaking in the late afternoon or evening.
B. Stress activates the sympathetic nervous system, which increases metabolic activity and raises body temperature rather than lowering it.
C. Physical activity generates heat, leading to an increase in body temperature, not a decrease.
D. While some surgical preparations involve cooling the patient, body temperature is not naturally lower before surgery. Instead, preoperative anxiety may even cause a slight increase in temperature.
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