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 D
Explanation
A. Documenting the patient's need for restraints is important but does not address the issue of restraining a competent patient against their will. This is an issue of patient rights and autonomy.
B. Not informing the patient is inappropriate, but the key issue is the lack of consent to be restrained, not just the failure to inform.
C. While failing to get a physician's order is critical for legal and safety reasons, the core issue here is the violation of the patient's autonomy and rights.
D. Restraining a competent patient against their will without consent is considered an intentional tort because it involves touching the patient in an unauthorized manner, which is a direct violation of their rights. This can result in legal action for assault or battery.
Correct Answer is B
Explanation
A. Discontinuing the tube feeding and transitioning to parenteral nutrition is not the first action, as the residual volume may be manageable with additional interventions.
B. A residual volume of 200 mL is above the usual threshold, so the nurse should stop the feeding, wait, and recheck the residual to assess if it improves.
C. While positioning can help gastric emptying, the immediate action should be to stop the feeding and reassess before continuing.
D. Continuing the feeding without rechecking the residual volume would be premature, as the volume is higher than expected, potentially increasing the risk of aspiration.
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