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 reason:

Increased haemoglobin is correct. level Epoetin alfa is a medication used to stimulate the production of red blood cells in the bone marrow, and it is often prescribed to treat anaemia. Anaemia is characterized by a decrease in the number of red blood cells or a decrease in the amount of haemoglobin, which is responsible for carrying oxygen in the blood.

The therapeutic response to epoetin alfa is an increase in the haemoglobin level. This indicates that the medication is effectively stimulating the production of red blood cells, leading to an improvement in the client's anaemia and overall oxygen-carrying capacity of the blood.

Choice B reason:

Increased platelet count: Platelets are involved in blood clotting and are not directly affected by epoetin alfa.

Choice C reason:

Increased neutrophil count: Neutrophils are a type of white blood cell involved in the body's immune response. Epoetin alfa primarily affects red blood cells and does not directly impact white blood cell levels.

Choice D reason:

Increased erythrocyte sedimentation rate (ESR): ESR is a non-specific indicator of inflammation in the body and is not directly related to the therapeutic response of epoetin alfa in treating anaemia.

A. Instruct the client to exhale while inserting the rectal tube. B. Insert the tip of the rectal tube 15 cm (6 in). C. Administer the enema using cool tap water. D. Administer a second enema if the first has poor results.

Correct Answer is A

Explanation

The correct answer is A. The nurse should instruct the client to exhale while inserting the rectal tube to relax the anal sphincter and facilitate insertion. The other options are

incorrect because they can cause injury or discomfort to the client.

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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 evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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