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 D
Explanation
A. Clinical breast examinations are generally recommended every 1 to 3 years for women in their 20s and 30s and annually for women 40 and older. However, the emphasis has shifted towards mammography as a primary screening tool.
B. Routine screening for colorectal cancer typically begins at age 45 for average-risk individuals, not 40. Colonoscopies are generally recommended every 10 years if results are normal.
C. Mammograms are typically recommended to start at age 40 for average-risk women, with yearly screening starting at age 45 or 50 depending on guidelines.
D. Annual testing for fecal occult blood is a recommended screening method for colorectal cancer starting at age 45, as it helps detect blood in the stool which can be an early sign of colorectal cancer.
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.
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