A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

Muscle strength

Urinary output

Pain sensation

Heart rhythm

Answer and Explanation

The Correct Answer is D

The correct answer is D. Heart rhythm. Hypothermia can cause cardiac dysrhythmias such as bradycardia, atrial fibrillation, and ventricular fibrillation, which can lead to cardiac arrest.

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Correct Answer is A

Explanation

Choice A rationale:

This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.

Choice B rationale:

Applying the stockings before the client gets out of bed is correct. Antiembolic stockings should be applied before the client gets out of bed to prevent blood from pooling in the legs, which can help reduce the risk of deep vein thrombosis (DVT).

Choice C rationale:

Asking the client to point their toes before applying the stockings is a correct action. This helps in the proper fitting of the stockings and ensures they are applied smoothly without causing discomfort.

Choice D rationale:

Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.

A. Request an x-ray of the preschooler's neck. B. Initiate droplet precautions. C. Administer fluconazole to the preschooler. D. Monitor the preschooler's urine for protein

Correct Answer is B

Explanation

The correct answer is B.

Initiate droplet precautions. The rationale is that RSV is a highly contagious viral infection that causes respiratory tract inflammation and can spread through respiratory droplets from coughing or sneezing. The nurse should wear a mask and gloves when caring for the preschooler and isolate them from other children to prevent transmission.

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A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is A

Explanation

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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