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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.)

A.

Remove tight clothing.

B.

Administer acetaminophen.

C.

Give salt tablets.

D.

Place in cool water.

E.

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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Related Questions

Correct Answer is C

Explanation

A. Excessive fluid losses may lead to dehydration, but this is not typically a primary concern for patients with pulmonary alterations unless there is significant vomiting, diarrhea, or blood loss.
B. Hemodilution is not a common concern in patients with pulmonary alterations. Hypernatremia typically occurs with fluid loss or inadequate fluid intake, but it is not a direct concern related to pulmonary issues.
C. Fluid volume excess can lead to right-sided heart failure in patients with pulmonary alterations. If fluid accumulates, it can worsen pulmonary symptoms and increase the workload on the heart, potentially leading to right-sided heart failure.
D. Fluid retention with tachypnea is not typically a direct cause of fluid retention. While tachypnea is associated with respiratory distress, fluid retention is more closely linked to heart failure or kidney dysfunction.

Correct Answer is D

Explanation

A. Administering an enema every third day may be too infrequent to effectively manage constipation. Enemas are generally not a first-line solution for constipation prevention in patients on long-term opioid therapy.
B. Constipation is nothing to worry about; take your medicine is incorrect because constipation is a common and preventable side effect of opioid use. It should be addressed proactively.
C. Only taking morphine when experiencing the most severe pain could lead to uncontrolled pain. It is important for cancer pain to be managed consistently, and adjusting the timing of medication is not recommended.
D. Increasing fluids and high-fiber foods, and using a mild laxative is the most appropriate recommendation. It helps prevent constipation, which is a common side effect of opioid use. Mild laxatives can also be helpful, but regular bowel care is essential.

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