An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4" F (40.8" C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

Give acetaminophen (Tylenol) rectal suppository.

Provide O2 at 2 L/min with a nasal cannula.

Apply wet sheets and a fan to the patient

Start lactated Ringer's solution at 1000 mL/hr

Answer and Explanation

The Correct Answer is C

A. Giving acetaminophen is appropriate for fever reduction but does not address the hypotension and potential dehydration in this scenario.
B. Providing oxygen is important, but the patient's hypotension requires fluid resuscitation as the initial priority.
C. Applying wet sheets and a fan are immediate actions focused on rapid cooling. The priority is to lower the body temperature as quickly as possible to prevent organ damage.
D. Starting lactated Ringer's solution at a high rate is crucial to address hypovolemia and to cool the patient effectively through intravenous hydration but should be done after cooling the patient using a wet sheet.

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Correct Answer is D

Explanation

A. Applying calamine lotion can provide relief from itching but does not address potential complications such as swelling or allergic reactions.
B. Applying ice packs can help reduce swelling and pain, but it is not the priority action in this scenario.
C. Attempting to remove the patient's rings is crucial to prevent complications such as restricted blood flow due to swelling, which can be exacerbated by bee stings. However, this should be done after administering diphenhydramine.
D. The nurse should first administer diphenhydramine (Benadryl) 50 mg PO to counteract the effects of the bee venom and reduce the risk of anaphylaxis.

A. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically B. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive C. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site D. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

Correct Answer is C

Explanation

A. While painful, a simple fracture and scratches do not pose an immediate threat to life compared to other injuries.
B. The client with severe head injuries and a low respiratory rate may seem like a priority, but if they are unresponsive and have a respiratory rate as low as 6/min, they may be beyond help.
C. A punctured chest with an audible hissing sound indicates a potential tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent collapse of the lung and other potentially fatal complications.
D. A pregnant woman with cuts and abrasions should be evaluated promptly but is not as critical as clients with severe head injuries or tension pneumothorax.

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An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4" F (40.8" C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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