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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "I'll use pursed-lip breathing when I feel short of breath.": Pursed-lip breathing is a beneficial technique for clients with COPD as it helps keep the airways open longer, reduces the work of breathing, and improves ventilation. This statement indicates the client understands a key management strategy for COPD.
B) "I'll skip my exercises for the week if I feel short of breath.": Regular exercise is important for managing COPD, and while adjustments may be necessary when symptoms are severe, completely skipping exercise can lead to deconditioning and worsening of symptoms. This statement does not reflect appropriate management of COPD.
C) "I will use my inhaler 30 minutes after each meal.": Inhalers should be used as prescribed, usually before activities that might trigger symptoms, such as eating, rather than on a fixed schedule unrelated to symptoms or physician's guidance. This statement indicates a misunderstanding of inhaler use.
D) "I will limit myself to drinking only 1 quart of water each day.": Staying hydrated is important for thinning mucus in COPD. Unless there are specific medical reasons to restrict fluids, such as heart failure, limiting water intake could lead to dehydration and thickened mucus, making breathing more difficult. This statement is not appropriate for managing COPD.
Correct Answer is D
Explanation
A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.
B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.
C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.
D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.
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