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Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Place ice packs around the client's head

Microwave a pack of gauze and distribute across the body

Administer intravenous fluids with a rapid infuser

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Use a fluid warmer for intravenous fluids

Apply warm blankets

Administer an antipyretic

Answer and Explanation

Correct Answer : C,D,E,F,G

A. Place ice packs around the client's head: This is a cooling intervention used for hyperthermia, not for treating hypothermia.
B. Microwave a pack of gauze and distribute across the body: This is unsafe, as microwaved materials can cause burns and do not provide effective heat distribution.
C. Administer intravenous fluids with a rapid infuser: Rapid infusion of warmed IV fluids can help restore core body temperature and prevent further hypothermia.
D. Check the temperature of the humidified oxygen attached to the ventilator: Cold or dry oxygen can contribute to heat loss, so ensuring that the humidified oxygen is warmed is an important step in maintaining normothermia.
E. Instill warm fluids in the nasogastric tube: Lavage with warm fluids via NG tube is an effective method of internal warming for hypothermic patients.
F. Use a fluid warmer for intravenous fluids: Warming IV fluids before administration prevents additional heat loss that could occur if room-temperature fluids are given.
G. Apply warm blankets: Passive external warming using warm blankets is an easy and effective intervention to increase body temperature.
H. Administer an antipyretic: Antipyretics (e.g., acetaminophen, ibuprofen) are used for fevers, not for hypothermia.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C"]

Explanation

A. Immediate notification of the healthcare provider is not warranted unless there are signs of complications, such as excessive bleeding or infection.

B. Applying a cold pack to the scrotal and penile areas can help reduce swelling and discomfort after TURP.

C. Putting a pillow under the buttocks can help reduce pressure on the surgical site and may improve comfort and circulation.

D. The indwelling catheter should not be removed unless there is a medical reason or complication that requires it.

E. A urinalysis is generally not needed unless there are signs of infection or hematuria.

A. Identify information as late entry in the record. B. Print electronic medical record (EMR) from backup server. C. Notify Information services department of the situation. D. Wait for notification that the system has been rebooted.

Correct Answer is C

Explanation

A. Identify information as late entry in the record. This action would only be necessary after the issue is resolved and documentation is restored.
B. Print electronic medical record (EMR) from backup server. While printing from the backup server is an option, notifying IT should be done first to address the root cause of the issue.
C. Notify Information services department of the situation. The IT department can assist in troubleshooting the issue and restoring the system to normal function.
D. Wait for notification that the system has been rebooted. It’s important to act proactively by notifying IT to help resolve the problem.

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Exhibits The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","C"]

Explanation

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Correct Answer is C

Explanation

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.