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 A
Explanation
A. This statement is incorrect because tacrolimus (an immunosuppressant) is typically required long-term to prevent organ rejection after a kidney transplant. Stopping it prematurely can lead to rejection.
B. This statement is correct because immunosuppressant drugs used after a kidney transplant often target different pathways to prevent rejection.
C. This statement is correct because acute rejection episodes may necessitate adjustments or additions to the immunosuppressive regimen.
D. This statement is correct because immunosuppressive medications increase the risk of certain cancers, so close monitoring is essential.
Correct Answer is C
Explanation
A. Oxygen administration is not indicated for acetaminophen overdose unless respiratory distress is present.
B. Drinking water does not address acetaminophen overdose and its potential liver toxicity.
C. N-acetylcysteine is the antidote for acetaminophen overdose and should be administered to prevent liver damage.
D. Chelation therapy is not used in the treatment of acetaminophen overdose.
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