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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
Correct Answer is C
Explanation
This action is intended to prevent a sentinel event, which is a patient safety event that results in death, permanent harm, or severe temporary harm. A sentinel event is a serious adverse event that signals the need for immediate investigation and response. Removing the wrong arm would be a devastating and irreversible outcome for the patient and the health care provider.
Choice A is wrong because the lack of healing of the stump is not a sentinel event. It is a possible complication of amputation that may be related to the natural course of the patient’s illness or underlying condition.
Choice B is wrong because ineffective control of the client’s pain is not a sentinel event. It is a quality of care issue that may affect the patient’s comfort and recovery, but it does not result in death, permanent harm, or severe temporary harm.
Choice D is wrong because the client being mildly sedated is not a sentinel event. It is a level of anesthesia that may be appropriate for some types of surgery, but it does not result in death, permanent harm, or severe temporary harm.
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