A nurse in an emergency department is caring for a preschooler who experienced a near drowning and has hypothermia. Which of the following actions should the nurse take?

Place the child in a tub bath of tepid water.

Cover the child's head with a hat.

Administer acetaminophen every 4 hr.

Obtain a specimen for blood cultures.

Answer and Explanation

The Correct Answer is B

A) Place the child in a tub bath of tepid water: While tepid water can help in some situations of hyperthermia, it is not suitable for hypothermia. A more controlled and gradual rewarming method is necessary to prevent further complications such as rewarming shock.

B) Cover the child's head with a hat: Covering the child's head with a hat is an important step in rewarming because a significant amount of body heat is lost through the head. This helps in retaining body heat and stabilizing the child’s temperature.

C) Administer acetaminophen every 4 hr: Acetaminophen is typically used for reducing fever and managing pain. It is not indicated for treating hypothermia, as it does not aid in rewarming the body or addressing the underlying hypothermic condition.

D) Obtain a specimen for blood cultures: While obtaining blood cultures might be necessary if there is a suspicion of infection, it is not a primary intervention for treating hypothermia. Immediate focus should be on rewarming and stabilizing the child.

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Correct Answer is D

Explanation

A) Metabolic acidosis: In metabolic acidosis, you would expect a low pH (acidosis) with a low bicarbonate (HCO3-) level. However, the given bicarbonate level is within the normal range (22-26 mEq/L), which indicates the acidosis is not metabolic in origin.

B) Metabolic alkalosis: Metabolic alkalosis would present with a high pH (alkalosis) and an elevated bicarbonate (HCO3-) level. The pH in this case is low, indicating acidosis, and the bicarbonate level is normal, ruling out metabolic alkalosis.

C) Respiratory alkalosis: In respiratory alkalosis, you would see a high pH (alkalosis) and a low PaCO2 due to hyperventilation. The given pH is low, indicating acidosis, and the PaCO2 is elevated, which is inconsistent with respiratory alkalosis.

D) Respiratory acidosis: Respiratory acidosis is characterized by a low pH (acidosis) and an elevated PaCO2 due to hypoventilation or impaired gas exchange. The client's ABG results show a low pH (7.2), a normal bicarbonate level (26 mEq/L), and an elevated PaCO2 (52 mm Hg), indicating the client is experiencing respiratory acidosis.

A. Check skin temperature distal to the injury with the dorsum of the hand. B. Press the heel of the foot to determine capillary refill. C. Monitor sensation by palpating the pad of the great toe with a blunt needle. D. Compare the color of the skin proximal to the injury with the other extremity.

Correct Answer is A

Explanation

A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.

B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.

C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.

D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.

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A nurse in an emergency department is caring for a preschooler who experienced a near drowning and has hypothermia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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