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. An assistive personnel is late for the upcoming shift: Tardiness is an issue of staff performance or scheduling rather than client safety, and it should be addressed through administrative or managerial processes. It does not require an incident report unless it directly results in harm or neglect to a client.

B. A client refuses to eat at mealtime: Client refusal to eat is a common occurrence and is managed through nutritional assessments and care planning. While it should be documented in the medical record, it does not constitute an unusual or adverse event that requires an incident report.

C. A family member is napping in the client's room: A family member resting in the room is not an incident unless it interferes with care or violates facility policy. This situation is not associated with client harm or safety risk, so it does not meet the criteria for incident reporting.

D. A client's bed alarm is malfunctioning: A malfunctioning bed alarm is a safety issue, particularly for clients at risk of falls. It represents a potential hazard that could lead to client injury, making it necessary to complete an incident report to document the problem and prompt timely intervention or equipment repair.

A. Speak with a loud voice while providing the information. B. Determine the client's ability to use a communication board. C. Provide the teaching without expecting the client to respond. D. Avoid the use of facial gestures during the instructions.

Correct Answer is B

Explanation

A. Speak with a loud voice while providing the information: Increasing the volume of speech is not effective for clients with expressive aphasia because their difficulty lies in producing language, not hearing. Speaking loudly may cause frustration or discomfort without improving communication.

B. Determine the client's ability to use a communication board: Assessing the client’s ability to use a communication board is an essential strategy to facilitate effective communication. Augmentative tools like communication boards can help them convey their needs and participate in teaching.

C. Provide the teaching without expecting the client to respond: Teaching without expecting any response can lead to missed opportunities for interaction and engagement. Encouraging some form of response, even nonverbal or through assistive devices, helps evaluate the client’s comprehension and maintains their involvement.

D. Avoid the use of facial gestures during the instructions: Facial gestures, body language, and visual cues play an important role in enhancing communication for clients with aphasia. Using expressive gestures should be encouraged to supplement verbal teaching and promote better comprehension.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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