A nurse is caring for a client who has moderate hypothermia. Which of the following actions should the nurse take?

Place the client in a semi-Fowler's position,

Infuse warm IV fluids.

Assess the client's skin hourly when using a heating blanket.

Rewarm the client's extremities first.

Answer and Explanation

The Correct Answer is B

A) Place the client in a semi-Fowler's position:
While positioning can be beneficial for various conditions, it does not directly address the core issue of hypothermia. Rewarming the client effectively is the primary concern in hypothermia management.

B) Infuse warm IV fluids:
Administering warm IV fluids is a crucial intervention for moderate hypothermia as it helps increase the client's core body temperature more rapidly and effectively. This method ensures that the body's internal temperature is raised, which is vital for stabilizing the client.

C) Assess the client's skin hourly when using a heating blanket:
Monitoring the skin is important to prevent burns or skin damage from a heating blanket, but it is a supportive measure rather than a primary intervention. The key priority is to rewarm the client’s core.

D) Rewarm the client's extremities first:
Rewarming the extremities first can actually be harmful in hypothermia, as it can lead to a drop in core body temperature due to the return of cold blood from the periphery to the core (afterdrop). The focus should be on warming the core body first.

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Correct Answer is C

Explanation

A) "What are you looking forward to each day?": While asking about daily expectations can provide insight into the client's coping mechanisms and hopefulness, it does not immediately address potential safety concerns. It is a helpful question for assessing the client's adjustment but not the priority if there is a concern about suicidal ideation.

B) "Can you tell me about your sleep patterns?": Sleep patterns are important for understanding overall well-being, especially during grief. However, this question is secondary to addressing the immediate risk of self-harm. Assessing sleep can come after determining if the client is having suicidal thoughts.

C) "Have you ever felt like you don't want to live anymore?": This question is crucial because it directly assesses the client's risk of suicidal ideation or self-harm. Given the client's recent loss and current symptoms, it is important to evaluate if there is a risk to their safety, making this the priority question.

D) "Are you taking any medications at this time?": While it is important to know about the client's medication use, this question does not address the immediate risk of self-harm or assess the psychological impact of the recent loss. Medication information is less urgent compared to evaluating suicidal thoughts.

A. Ask the client how she feels about her understanding of diabetes. B. Ask the client how often she reads food labels. C. Ask the client to explain what she read from a brief handout about diabetes management. D. Ask the client when she last had her HbA1c checked.

Correct Answer is C

Explanation

A) Asking the client how she feels about her understanding of diabetes can provide some insight into her confidence and perceived knowledge. However, it does not objectively measure her actual understanding or ability to apply diabetes management information.

B) Asking the client how often she reads food labels assesses a specific behavior related to diabetes management but does not fully evaluate the client's overall health literacy. The frequency of reading food labels may indicate some level of engagement, but it does not necessarily reflect comprehensive understanding or effective diabetes self-management.

C) Requesting the client to explain what she read from a brief handout about diabetes management provides a direct assessment of her comprehension and retention of diabetes management information. This approach effectively measures her ability to understand and apply critical health information, which is a core component of health literacy.

D) Inquiring about the timing of her last HbA1c test assesses adherence to diabetes monitoring but does not gauge the client's understanding of diabetes management. While important, this question does not provide a clear picture of her health literacy or ability to manage her condition effectively.

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A nurse is caring for a client who has moderate hypothermia. Which of the following actions should the nurse take?

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