A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?

Cover the pad prior to use.

Fill the pad with sterile water.

Apply the pad for 45 min at a time.

Use safety pins to secure the pad in place.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, "Cover the pad prior to use." This is a necessary precaution to prevent burns. Choice B is incorrect because filling the pad with sterile water is not necessary. Choice C is incorrect because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is incorrect because using safety pins to secure the pad in place can puncture the pad and cause burns. Choice B is not correct because filling the pad with sterile water is not necessary. Choice C is not correct because aquathermia pads should only be applied for 20-30 minutes at a time. Choice D is not correct because using safety pins to secure the pad in place can puncture the pad and cause burns.

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Correct Answer is A

No explanation

A. Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F). B. Respiratory rate change from 12/min to 20/min. C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg. D. Heart rate change from 110/min to 68/min.

Correct Answer is C

Explanation

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.

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A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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