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. Applying hydrating lotions helps moisturize and soothe the skin, which can alleviate dryness and scaling after radiation treatment.
B. Sitting in the sun can exacerbate skin damage and should be avoided after radiation therapy.
C. Moist heat can increase skin irritation and is not recommended for soothing radiation-damaged skin.
D. Washing with plain soap and water is appropriate but should be done gently to avoid further irritation.
Correct Answer is D
Explanation
A. Guardedsuggests uncertainty, which may understate the seriousness of stage IV disease.
B. "Good" and "very good" prognoses suggest favorable outcomes, which are less likely with stage IV ovarian cancer.
C. "Poor" prognosis indicates a bleak outlook with limited treatment options and expected decline in health.
D.Stage IV ovarian cancer indicates advanced disease with metastasis to distant organs, such as the liver or lungs. Even with aggressive treatment (surgery, radiation, chemotherapy), the overall survival rate is low, and the prognosis is considered poor. Discussing a poor prognosis allows the client to make informed decisions about treatment options, advance care planning, and supportive care.
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