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 ["B","D","E"]

Explanation

A. Room number: Room number is not a reliable client identifier because clients can be moved or rooms reassigned, which increases the risk of medication errors or misidentification.

B. Photo identification: Using photo identification is a reliable way to confirm the client’s identity, ensuring that medications are given to the correct person by visually matching the client’s face.

C. Diagnosis: Diagnosis alone is not a unique identifier since multiple clients can share the same diagnosis, and it does not confirm identity for medication administration purposes.

D. Facility-assigned identification number: This number is a unique identifier assigned to each client and is commonly used in healthcare settings to verify identity accurately before medication administration.

E. Date of birth: Date of birth is a reliable identifier to cross-check client identity, especially when used with other identifiers, reducing the risk of errors during medication administration.

A. Impaired hearing B. Reduced health literacy C. Lower extremity weakness D. Texting while driving

Correct Answer is D

Explanation

A. Impaired hearing: Impaired hearing can increase the risk of injury by reducing the client’s ability to hear alarms or warnings. However, it is considered a sensory impairment rather than a lifestyle choice.

B. Reduced health literacy: Low health literacy can contribute to poor understanding of safety instructions and adherence to precautions, increasing injury risk. Nonetheless, it relates more to knowledge deficits than lifestyle behaviors.

C. Lower extremity weakness: Weakness in the legs increases fall risk due to impaired mobility and balance. This is a physical or functional risk factor rather than a lifestyle risk.

D. Texting while driving: Texting while driving is a high-risk lifestyle behavior directly associated with increased injury and accident rates. It involves voluntary behavior that compromises safety and is a preventable cause of injury.

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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 in a long-term care facility is preparing to administer medications to a group of clients. Which of the following are acceptable client identifiers for the nurse to use? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is D

Explanation

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