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 A
Explanation
A. Neutropenic clients have reduced immune function and are at increased risk of infection from exposure to crowds and potential pathogens.
B. Taking temperatures daily, not weekly, is important to monitor for signs of infection in neutropenic clients.
C. Mild exercise is generally encouraged but should be discussed with the healthcare provider to ensure safety and infection prevention.
D. Fresh fruits and vegetables are important for overall nutrition but should be washed thoroughly to reduce the risk of infection.
Correct Answer is B
Explanation
A. Placing the client's clothing in a plastic bag may be necessary for preserving evidence but does not address immediate safety concerns.
B. Instructing the client to remove their clothing helps reduce further exposure to the unknown chemical.
C. Maintaining a safe distance from the client is important, but immediate decontamination is a higher priority.
D. Showering and scrubbing the client's skin should be done after removing contaminated clothing to minimize exposure.
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