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 A

Explanation

A. Syringe: A syringe is essential for irrigating a stage 4 pressure injury to cleanse the wound thoroughly without causing trauma to the tissue. Proper irrigation helps remove debris and bacteria, promoting healing. A syringe allows controlled, gentle flushing of the wound bed, which is important in managing deep, complex wounds like stage 4 pressure injuries.

B. Tongue depressor: A tongue depressor is generally used to examine the throat and oral cavity and is not suitable for wound care. It lacks the precision and safety needed for wound cleaning or dressing application, especially for deep pressure ulcers.

C. Adhesive tape: Adhesive tape is used to secure dressings but is not a primary supply for wound care itself. In managing a stage 4 pressure injury, the priority is proper wound cleaning and dressing materials rather than just securing them, so adhesive tape is secondary.

D. Cotton-tipped applicator: Cotton-tipped applicators are commonly avoided in wound care because they can leave fibers in the wound bed and potentially cause trauma or infection. They are not recommended for cleaning or applying medication to deep pressure ulcers, where more sterile, gentle methods are needed.

A. "Why do you think you are dying?" B. "I think you should have some quiet time to get some rest." C. "You are concerned that you are dying?" D. "It is normal to feel this way with your type of cancer."

Correct Answer is C

Explanation

A. "Why do you think you are dying?" This question can sound confrontational and may cause the client to feel defensive. It does not acknowledge the client’s feelings or encourage further communication about their concerns.

B. "I think you should have some quiet time to get some rest." While rest is important, this response dismisses the client’s emotional expression and does not address their fear or need for support regarding dying.

C. "You are concerned that you are dying?" This statement reflects the client’s feelings and encourages them to share more about their fears and concerns. It validates their emotions and opens a supportive dialogue.

D. "It is normal to feel this way with your type of cancer." Although normalizing feelings can be helpful, this response might minimize the client’s personal experience and does not directly explore their expressed worry about dying.

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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

A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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