A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

Apply a heating pad to the client's neck.

Provide the client with dry clothing.

Offer the client a warm beverage.

Wrap the client in warm blankets.

Answer and Explanation

The Correct Answer is B

A. Apply a heating pad to the client's neck: Direct application of heat to the skin, especially in localized areas like the neck, can cause rapid vasodilation, leading to a dangerous drop in blood pressure and potential cardiac complications. It also increases the risk of burns on cold-numbed skin.

B. Provide the client with dry clothing: Removing wet clothing and replacing it with dry garments is the first priority in managing hypothermia. Wet clothes accelerate heat loss through conduction and evaporation. Stopping further heat loss is essential before attempting active rewarming.

C. Offer the client a warm beverage: While offering warm fluids can help increase core temperature and provide comfort, it is not the first priority. This intervention is more appropriate after ensuring the client is dry and wrapped in warm coverings.

D. Wrap the client in warm blankets: Wrapping the client in warm blankets is a critical intervention for passive external rewarming. However, it comes after the initial step of removing wet clothes to prevent ongoing heat loss. Blankets are most effective once the source of heat loss has been eliminated.

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Free Nursing Study Resources

Correct Answer is ["B","A","C","D"]

Explanation

A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.

B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.

C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.

D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.

A. Ensure the oxygen delivery system is at least 8 feet from any heat source. B. Store the oxygen cylinder wrench with the oxygen tank. C. Adjust the oxygen flow rate as needed to ease breathing. D. Take antibiotic medication with or without food. E. Take steroid medication in the morning. F. Decrease the steroid dose each day. G. Take antibiotics for 10 days.

Correct Answer is ["A","B","E","G"]

Explanation

A. Ensure the oxygen delivery system is at least 8 feet from any heat source: Oxygen is flammable, and this safety measure helps prevent fire hazards in the home environment.

B. Store the oxygen cylinder wrench with the oxygen tank: Keeping the wrench with the tank ensures quick and easy access in case the oxygen needs to be turned on or off during an emergency.

C. Adjust the oxygen flow rate as needed to ease breathing: Clients should never adjust oxygen flow independently; flow rate changes must be prescribed and monitored by the healthcare provider to prevent complications like oxygen toxicity or hypoventilation.

D. Take antibiotic medication with or without food: This varies by antibiotic. Cefazolin, for example, was given IV in the hospital, and the oral form prescribed for home use might require food to reduce GI side effects; instructions should be drug-specific.

E. Take steroid medication in the morning: Steroids mimic the body’s natural cortisol rhythm; taking them in the morning minimizes insomnia and other endocrine side effects.

F. Decrease the steroid dose each day: Steroid tapering must follow a specific provider-prescribed regimen. Improper tapering can lead to adrenal insufficiency or withdrawal symptoms.

G. Take antibiotics for 10 days: Completing the full antibiotic course, even if symptoms improve, helps prevent antibiotic resistance and ensures complete eradication of the infection.

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A nurse at an urgent care center is assisting with the care of a client who has hypothermia after exposure to frigid water. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","A","C","D"]

Explanation

A nurse is assisting in the care of a client who has pneumonia. Exhibits The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

Correct Answer is ["A","B","E","G"]

Explanation

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