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The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Apply warm blankets

Use a fluid warmer for intravenous fluids

Place ice packs around the client's head

Administer an antipyretic

Administer intravenous fluids with a rapid infuser

Microwave a pack of gauze and distribute across the body

Answer and Explanation

Correct Answer : A,B,C,D,G

A. Check the temperature of the humidified oxygen attached to the ventilator: Ventilator circuits often include humidified air, and ensuring it is warm helps prevent further heat loss. Cold oxygen delivery can contribute to hypothermia in intubated clients.

B. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help raise core body temperature and are an appropriate method for internal rewarming in a hypothermic trauma patient.

C. Apply warm blankets: This is a safe, effective, and commonly used external warming method to treat mild hypothermia. Warm blankets help prevent further heat loss and support gradual rewarming.

D. Use a fluid warmer for intravenous fluids: Infusing cold fluids can worsen hypothermia. Using a fluid warmer helps maintain core temperature and is especially important during rapid fluid administration.

E. Place ice packs around the client's head: This intervention would lower body temperature and is contraindicated in hypothermia. It is used to reduce fever or manage increased intracranial pressure, not to treat low temperatures.

F. Administer an antipyretic: Antipyretics are used to reduce fever, not to raise body temperature. In a hypothermic client, they are inappropriate and potentially harmful.

G. Administer intravenous fluids with a rapid infuser: A rapid infuser should only be used with warmed fluids. When used with a fluid warmer, it helps maintain core temperature during large-volume resuscitation.

H. Microwave a pack of gauze and distribute across the body: This is unsafe and not evidence-based. Microwaving gauze creates a burn hazard and provides no controlled or measurable warming benefit.

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Correct Answer is ["A","C","D"]

Explanation

A. Institute contact precautions for staff and visitors: MRSA is a highly transmissible organism, especially through contact with wound drainage, so implementing contact precautions is essential to prevent spread.

B. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is used for immunocompromised clients, such as those with neutropenia or undergoing chemotherapy, but is not appropriate or relevant in the context of a MRSA wound infection.

C. Send wound drainage for culture and sensitivity: Culturing the wound helps identify the exact organism and determine the most effective antibiotic treatment, guiding targeted therapy for MRSA.

D. Monitor the client's white blood cell count: Monitoring WBC count is essential to assess the client’s immune response and track infection progression or resolution in osteomyelitis with suspected MRSA.

E. Use standard precautions and wear a mask: Standard precautions are always necessary, but a mask is not required for MRSA unless there is a risk of droplet transmission (e.g., respiratory MRSA), which is not indicated in this wound-related case.

A. Infectious process in the synovial fluid. B. Systemic inflammatory response. C. Destruction of joint cartilage. D. Loss of bone mineral density.

Correct Answer is C

Explanation

A. Infectious process in the synovial fluid: An infection in the synovial fluid would suggest septic arthritis, not osteoarthritis, which is a degenerative, non-infectious joint condition.

B. Systemic inflammatory response: A systemic inflammatory response is characteristic of autoimmune diseases like rheumatoid arthritis, not the localized wear-and-tear process of osteoarthritis.

C. Destruction of joint cartilage: Osteoarthritis involves the gradual breakdown and loss of cartilage, leading to pain, stiffness, and decreased joint mobility as bone surfaces begin to rub against each other.

D. Loss of bone mineral density: Loss of bone mineral density is related to osteoporosis, a different condition that affects bone strength but does not primarily cause joint pain and stiffness.

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The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is C

Explanation

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