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?
Administering aspirin to the patient
Providing oral fluids
Applying a cooling blanket
Giving salt tablets to the patient
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A high fat, low carbohydrate formula is most appropriate for patients with poorly controlled diabetes mellitus, as it helps stabilize blood glucose levels while still providing necessary nutrition.
B. A concentrated calorie formula may not be appropriate for this patient as it could lead to hyperglycemia due to increased glucose intake.
C. Whole proteins and glucose polymers might increase the glucose load and exacerbate poor blood sugar control.
D. While low sodium is important for many conditions, it is not the primary concern for managing poorly controlled diabetes mellitus in the context of enteral nutrition.
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.
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