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 B

Explanation

The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.

Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.

Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.

The client might not be able to access the hotline or might be afraid to use it.

Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.

The nurse should not assume that the family member is willing or able to provide adequate care for the client.

Respite care might be an option after the abuse is reported and investigated.

A. Hourly vital signs. B. Implementing all fall risk precautions. C. Utilizing bariatric bed and trapeze bar. D. Supine positioning.

Correct Answer is C

Explanation

A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.

These interventions can promote comfort, safety, and independence for the patient.

Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.

Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.

Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.

The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.

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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

Correct Answer is B

Explanation

A nurse is caring for a patient with a BMI of. Appropriate nursing interventions include:

Correct Answer is C

Explanation

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A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

The nurse is performing a cultural assessment with a client; the nurse should include which of the following? (Select All That Apply).

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