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 A

Explanation

A) Talk about the special features of the baby with the client: This intervention acknowledges the baby as a real person and can provide comfort to the grieving parents by validating their loss and giving them a chance to create memories, which is an important aspect of the grieving process.

B) Post a sign indicating No Visitors: This may not be appropriate as it might isolate the client further. Some parents may want the support of family and friends during this difficult time, and such a restriction should be based on the parents' wishes rather than a standard protocol.

C) Limit the amount of time the client is allowed to have the baby in her room: Allowing parents to spend as much time as they need with their baby can help them with the grieving process. Placing limits might be perceived as insensitive and could hinder the emotional healing process.

D) Tell the parents they should hold their baby: While many parents find comfort in holding their stillborn baby, it should be offered as a choice rather than a directive. It is important to respect the parents' individual coping mechanisms and provide support based on their preferences.

A. "You should remain on a clear liquid diet for 1 week after surgery." B. "Avoid showering for 1 week after surgery." C. "Cleanse the incision sites with hydrogen peroxide." D. "Apply heat to the right shoulder for pain."

Correct Answer is D

Explanation

A) "You should remain on a clear liquid diet for 1 week after surgery.": After a laparoscopic cholecystectomy, clients do not need to remain on a clear liquid diet for a week. They can usually progress to a regular diet as tolerated, starting with light meals and avoiding fatty, greasy foods initially to prevent discomfort.

B) "Avoid showering for 1 week after surgery.": Clients are typically allowed to shower within a day or two after surgery, as long as they avoid soaking the incisions in water and follow the healthcare provider's instructions for incision care. Avoiding showering for a week is generally unnecessary and may hinder hygiene.

C) "Cleanse the incision sites with hydrogen peroxide.": Hydrogen peroxide can delay wound healing and is not recommended for routine incision care. The nurse should advise the client to cleanse the incision sites with mild soap and water and pat them dry.

D) "Apply heat to the right shoulder for pain.": Applying heat to the right shoulder can help relieve referred pain often experienced after a laparoscopic cholecystectomy due to residual gas used during the procedure. This is a common and effective method for managing postoperative discomfort.

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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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