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

The mother and the baby should have matching identification bands to prevent abduction or mix-up.

The mother should not remove her security band, as this can compromise her identity and safety.

The mother should not take her baby to the lobby or other public areas, as this can expose the baby to infection or harm.

The mother should use a bassinet or crib to transport her baby to the nursery, as this can prevent falls or injuries.

A. Maintain bed rest for 48 hr. B. Keep legs in a dependent position. C. Wrap the leg with an elastic bandage. D. Implement a sodium-restricted diet.

Correct Answer is C

Explanation

The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.

The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.

The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.

The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.

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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

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Correct Answer is C

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