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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates worsening in the client's condition since they are prone to infections.
B. In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C. In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D. In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E. The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.
Correct Answer is ["B","C","E"]
Explanation
A. Change in moles can indicate skin cancer.
B. Change in bowel pattern can be a sign of colorectal cancer.
C. A nonhealing sore can indicate skin cancer or other types of cancer that manifest as chronic wounds.
D. Bloating is less specific and may indicate various health conditions but are not typically primary signs of cancer.
E. Nagging cough is can be a sign of lung and/or throat cancer.
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