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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Correct Answer is D

Explanation

A. The stoma protrudes slightly from the abdomen: A stoma that protrudes slightly (about 1–2 cm) above the skin surface is normal and indicates healthy placement. This finding does not require reporting.

B. The stoma bleeds lightly when touched: Light bleeding with gentle palpation or cleaning is common due to the stoma’s rich blood supply and is generally not concerning unless bleeding is excessive.

C. The stoma is draining a small amount of liquid stool: Liquid stool drainage is expected from a colostomy, especially in the early postoperative period. This is a normal finding that does not require reporting.

D. The stoma appears dark in color: A dark, dusky, or black stoma indicates compromised blood flow and possible ischemia or necrosis. This is a serious finding that requires immediate reporting to prevent further complications.

A. Ask the assistive personnel to document the client's time of death. B. Wear sterile gloves when cleaning the client's body. C. Place an identification tag on the outside of the client's shroud. D. Remove the client's dentures and give them to the client's family.

Correct Answer is C

Explanation

A. Ask the assistive personnel to document the client's time of death: Documenting the time of death is a critical nursing responsibility and should be done by the nurse or healthcare provider, not delegated to assistive personnel. Accurate documentation is essential for legal and medical records, especially when an autopsy is planned.

B. Wear sterile gloves when cleaning the client's body: Sterile gloves are not necessary for routine postmortem care; clean gloves are sufficient. Sterile gloves are reserved for invasive procedures to prevent infection, whereas postmortem care focuses on hygiene and respect for the deceased.

C. Place an identification tag on the outside of the client's shroud: Proper identification of the deceased is crucial, especially when an autopsy is required. Placing an identification tag on the shroud ensures correct identification during transport and handling, preventing misidentification and maintaining respect for the client.

D. Remove the client's dentures and give them to the client's family: Dentures should typically remain in the client's mouth during postmortem care to preserve facial structure and appearance. Removing them can alter the deceased’s appearance, which may be distressing to the family and is generally avoided unless specifically requested.

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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

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