Your patient was outdoors and developed hypothermia.
You know that independent nursing interventions would include:

Soaking extremities in hot water.

Administering warmed intravenous fluids.

Administering hot whirlpool therapy.

Replacing wet clothing with dry clothing.

Answer and Explanation

The Correct Answer is D

Replacing wet clothing with dry clothing is an independent nursing intervention that can help prevent further heat loss and gradually warm the patient. Soaking extremities in hot water (choice A) is not recommended because it can cause vasodilation and hypotension. Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiac dysrhythmias.

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Correct Answer is C

Explanation

This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.

Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.

The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.

Choice B is wrong because it is not a goal statement, but an intervention.

A goal statement should describe the expected outcome of the intervention, not the intervention itself.

Choice D is wrong because it is not measurable or time-bound.

A goal statement should have a clear indicator of how and when the outcome will be achieved.

A. Encouraging the client to increase intake of foods that contain high fat to increase GI motility. B. Encouraging the client to increase solid food intake to promote peristalsis. C. Encouraging the client to increase intake of foods that contain fiber. D. Withholding food and oral fluids until intestinal mobility has returned.

Correct Answer is D

Explanation

Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.

Giving food and fluids to a client with POI may worsen the condition and cause complications.

Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.

Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.

Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.

Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.

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Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

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Naxlex Comprehensive Predictor Exams

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

Correct Answer is C

Explanation

The nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

Correct Answer is D

Explanation

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While preparing a client for surgery, the nurse marks the arm that is to be amputated and participates in a “time-out” procedure before the surgery begins. Which sentinel event is this action intended to prevent?

Your patient was outdoors and developed hypothermia. You know that independent nursing interventions would include:

Which thermoregulatory condition is an elderly person most at risk for?

Your patient was outdoors and developed hypothermia.
You know that independent nursing interventions would include: