Which action would the nurse take if the patient brought to the emergency after hiking in the desert for 2 hours is confused, reports hallucinations, and has a temperature of 104.2°F (40.1°C), dark amber urine, and a serum sodium of 128 mEq/L? (Select all that apply.)

Remove tight clothing.

Administer acetaminophen.

Give salt tablets.

Place in cool water.

Initiate intravenous (IV) fluids.

Answer and Explanation

Correct Answer : A,D,E

A. Removing tight clothing is correct because it allows for better heat dissipation and helps cool the patient.
B. Administering acetaminophen is incorrect as acetaminophen reduces fever from infection, not from heat stroke, which requires active cooling measures.
C. Giving salt tablets is incorrect as rapid sodium replacement can cause dangerous fluid shifts; IV fluids are preferred for controlled electrolyte correction.
D. Placing in cool water is correct because immersion cooling is one of the most effective methods to lower body temperature in heat stroke.
E. Initiating IV fluids is correct as the patient likely has dehydration and electrolyte imbalances, requiring fluid resuscitation with isotonic fluids.

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Correct Answer is C

Explanation

A. Administering aspirin is incorrect because aspirin is ineffective in reducing core temperature in heat stroke and can increase the risk of bleeding.
B. Providing oral fluids is incorrect because the patient is confused and at risk for aspiration; IV fluids are preferred.
C. Applying a cooling blanket is correct because this patient is experiencing heat stroke, and rapid cooling is essential to prevent organ damage. Cooling blankets, ice packs, and immersion in cool water are key interventions.
D. Giving salt tablets is incorrect as rapid sodium replacement can cause fluid shifts and worsen the condition; IV fluids are preferred.

A. Placing the patient in prone position to improve draining from mouth B. Checking to make sure the tracheostomy cuff is inflated during tube feedings C. Placing the patient in the right lateral decubitus position to promote gastric emptying D. Discussing the use of metoclopramide to facilitate gastric motility with the practitioner

Correct Answer is B

Explanation

A. The prone position is not recommended for managing tube feeding regurgitation, as it could lead to aspiration into the lungs.
B. The first priority is to ensure that the tracheostomy cuff is inflated during tube feedings to prevent aspiration and to ensure that the feeding is directed into the stomach and not into the airway.
C. The lateral decubitus position can help with gastric emptying, but the priority is to ensure proper cuff inflation to prevent aspiration.
D. While metoclopramide may help with gastric motility, the immediate concern is managing the risk of aspiration, which requires confirming cuff inflation.

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Which action would the nurse take if the patient brought to the emergency after hiking in the desert for 2 hours is confused, reports hallucinations, and has a temperature of 104.2°F (40.1°C), dark amber urine, and a serum sodium of 128 mEq/L? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Which intervention would the nurse plan to use for a patient who was working on a construction site and now presents to the hospital with profuse sweating, a temperature of 104°F (40°C), patent airway, tachycardia, acute confusion, and anxiety?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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