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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A) Contact dermatitis: This condition results from an allergic reaction or irritation caused by contact with a substance, such as chemicals, detergents, or allergens. It is not a communicable skin infection and does not spread from person to person.
B) Actinic keratoses: These are rough, scaly patches on the skin caused by prolonged exposure to ultraviolet (UV) rays. They are considered precancerous lesions and are not contagious. They result from environmental factors rather than person-to-person transmission.
C) Psoriasis: This is a chronic autoimmune condition that leads to the rapid buildup of skin cells, causing scaling on the skin's surface. It is not contagious and does not spread through person-to-person contact. Psoriasis is an inherited condition influenced by immune system triggers.
D) Herpes zoster: Also known as shingles, this condition is caused by the reactivation of the varicella-zoster virus (the same virus that causes chickenpox). While shingles itself is not spread from person to person, the virus can be transmitted from a person with shingles to someone who has never had chickenpox, potentially causing chickenpox in the latter individual. The virus is spread through direct contact with the fluid from the blisters.
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