Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?
The patient develops atrial fibrillation.
The core temperature is 94° F (34.4" C).
The BP decreases to 86/42 mm Hg.
The patient begins to shiver
The Correct Answer is B
A. Developing atrial fibrillation can be a complication of hypothermia, but rewarming is still necessary to address the underlying condition.
B. Active rewarming should be discontinued if the patient's core temperature reaches 94°F (34.4°C), as further active rewarming could lead to complications. It's important to transition to passive rewarming methods to allow the patient's temperature to normalize gradually.
C. A decrease in blood pressure may indicate hypovolemia or shock but does not necessarily require discontinuation of rewarming.
D. Shivering is a normal response during rewarming and does not indicate a need to discontinue rewarming efforts unless other complications arise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Insertion of an arteriovenous graft is not directly related to treating acute rejection but may be necessary if dialysis is needed.
B. Testing for HLA match is done before transplantation, not typically after acute rejection occurs.
C. Placement on the transplant waiting list is for patients who do not have a current functioning transplant.
D. Mycophenolate is an immunosuppressive medication commonly used to prevent or treat rejection in transplant patients.
Correct Answer is D
Explanation
A. While external bleeding is important to assess and manage, it is not the next immediate action after confirming an unobstructed airway.
B. Checking the patient's level of consciousness should be done after assessing the respiratory effort.
C. Palpating extremities for bilateral pulses is part of assessing circulation, which typically follows the assessment of consciousness.
D. After ensuring the patient has an unobstructed airway, the next step in the primary assessment is to observe the patient's respiratory effort. This is crucial as it provides immediate information about the adequacy of the patient's breathing and the need for supplemental oxygen or other interventions.
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