A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
Cover the adolescent with a thermal blanket.
Submerge the adolescent’s feet in ice water.
Initiate seizure precautions.
Administer oral acetaminophen.
The Correct Answer is C
Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.
Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.
Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.
Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should include this information in the teaching because suctioning is often needed to keep the tracheostomy tube and opening free from extra mucus and secretions that come from the lungs and tissue around the stoma. Suctioning can help prevent the tube from becoming plugged and improve breathing.
Choice A is wrong because the nondisposable tracheostomy tube does not need to be changed daily. It can be changed every 1 to 3 months, depending on the type of tube.
Choice C is wrong because the tracheostomy dressing should be changed using sterile technique, not clean technique, to prevent infection.
Choice D is wrong because the tracheostomy tube should not be secured with ties at the back of the neck. The ties should be fastened at the front or side of the neck, and they should be snug but not too tight.
Correct Answer is B
Explanation
The correct answer is choice B. Instruct the client to notify the provider if diarrhea develops.
Choice A rationale:
Infusing the medication over 10 minutes is incorrect because penicillin G should typically be infused over 15-30 minutes to ensure proper administration and reduce the risk of adverse reactions.
Choice B rationale:
Instructing the client to notify the provider if diarrhea develops is correct because diarrhea can be a sign of a serious side effect, such as antibiotic-associated colitis, which requires prompt medical attention.
Choice C rationale:
Refrigerating the medication after reconstitution is not necessary for penicillin G. This instruction is more relevant for other medications that require refrigeration to maintain stability.
Choice D rationale:
Checking the client for a sulfa allergy is not relevant to penicillin G, as it is not a sulfa drug. This action would be more appropriate for medications containing sulfonamides.
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