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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Preparing a 60-mL syringe with saline may be necessary for gastric lavage but is not the first action.
B. For an unconscious patient who has ingested a significant quantity of lorazepam, securing the airway is the most critical first step to prevent aspiration and ensure the patient can breathe. Therefore, the nurse should assist with intubation of the patient.
C. The initial step is to ensure that the client’s airway is secured through intubation before administration of activated charcoal.
D. Inserting a large-bore orogastric tube may be necessary for gastric lavage but typically follows administration of activated charcoal.

A. A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min B. A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky. C. An unconscious adult client who has a large head wound with gray matter exposed; absent respirations D. An unconscious 6-month-old infant with no respirations, no visible injuries

Correct Answer is A

Explanation

A. In mass casualty triage, priority is given to clients who are salvageable with immediate intervention. This client is conscious (airway is intact) but has respiratory distress (RR > 30/min), suggesting potential inhalation injury or early shock. Prompt treatment can be life-saving.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C.Unconscious adult with large head wound and exposed gray matter, absent respirationsis unsalvageable; in triage terms, this client would be black tag (expectant). Immediate care will not change survival.

D.Unconscious 6-month-old infant with no respirations, no visible injuriesis also considered unsalvageable without immediate resuscitation; triage prioritizes those with highest likelihood of survival.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

Correct Answer is B

Explanation

A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

Correct Answer is A

Explanation

A home health nurse is interviewing a client and asks the client, "Have you or your family been exposed to any chemical liquids, fumes, lead, or unusual smells?" Which type of assessment is the nurse conducting?

A nurse is caring for a client who is admitted to the emergency department for fatigue. Exhibits Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching?

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

A nurse is reviewing the laboratory results of a client who was admitted with a history of multiple myeloma. The nurse should expect to find an increase in which of the following laboratory values?

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?