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 client is sedentary throughout most of the day: While physical inactivity can lead to health issues such as muscle weakness and cardiovascular problems, it is not immediately life-threatening and can be addressed through lifestyle interventions.

B. The client verbalizes regret about never marrying: This reflects emotional distress or social isolation, which is important, but it does not pose an urgent physical health risk requiring immediate attention.

C. The client has no living family: Although lacking family support can affect long-term care planning and emotional well-being, it is not the most immediate threat to the client’s health in this context.

D. The client has poorly fitting dentures: This is the priority because it directly affects the client’s ability to eat, leading to potential malnutrition, weight loss, and decline in overall health—issues particularly dangerous for older adults.

A. Check the client's medical records to see which medications were recently administered. B. Notify the charge nurse of the client's condition. C. Review the client's most recent SaO2 level in the medical record. D. Recheck the client's SaO2 level after having the client cough and clear their throat.

Correct Answer is D

Explanation

A. Check the client's medical records to see which medications were recently administered:
While reviewing medications is important for understanding potential causes of hypoxia, it is not the immediate priority when a client’s oxygen saturation is low. Immediate assessment and intervention to improve oxygenation come first.

B. Notify the charge nurse of the client's condition: Notifying the charge nurse is important but should follow an initial assessment and attempt to address the problem. Immediate client reassessment takes precedence to determine the current status and possible interventions.

C. Review the client's most recent SaO2 level in the medical record: Checking prior oxygen saturation levels can provide context but does not directly address the acute finding of 88% saturation, which requires prompt evaluation and action.

D. Recheck the client's SaO2 level after having the client cough and clear their throat: This action directly addresses a common cause of transient hypoxia such as airway obstruction from secretions. Reassessment after clearing the airway is the priority to determine if oxygenation improves before escalating interventions.

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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?

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Naxlex Comprehensive Predictor Exams

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