Try Naxlex NCLEX-RN (Free-Trial)

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

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 []

Explanation

Potential condition:

TACO is a complication that can occur during or shortly after a blood transfusion, particularly in children. It happens when the volume of blood infused exceeds the circulatory system's ability to handle it, leading to fluid overload. In this case, the child is receiving 250 mL of packed red blood cells (PRBCs), and there are signs that the child may be experiencing fluid overload, such as tachycardia, hypotension, headache, and flushing. The elevated heart rate (115 beats/minute) and low blood pressure (88/44 mm Hg) after the transfusion started suggest that the child may be at risk for circulatory overload. These symptoms, combined with the increased temperature (100.9°F, 38.3°C), further support the likelihood of TACO.

Actions to Take:

Stop the blood transfusion: This is the first and most important step when transfusion-related complications, such as TACO, are suspected. Stopping the transfusion immediately helps to prevent further exacerbation of the fluid overload, which could lead to worsening respiratory distress and circulatory compromise.

Administer an antipyretic: The child has developed a fever (100.9°F), which could be a response to the transfusion. Administering an antipyretic such as acetaminophen or ibuprofen can help manage the fever, provide comfort, and prevent further complications. Fever management is important, especially in transfusion reactions, as it helps reduce the risk of complications such as febrile non-hemolytic transfusion reactions (FNHTR).

Parameters to Monitor:

Blood pressure: Monitoring the blood pressure is critical in assessing the child’s circulatory status. A low blood pressure (88/44 mm Hg), especially in the context of tachycardia, indicates that the child is experiencing hypotension, which is often associated with circulatory overload. Close monitoring of blood pressure will help guide the decision to start appropriate treatments, such as diuretics, to manage the overload.

Hematocrit: The hematocrit value provides information about the oxygen-carrying capacity of the blood. Given that the child’s hemoglobin was 6.5 g/dL (65 g/L) prior to the transfusion, it’s important to continue monitoring the hematocrit to assess the effectiveness of the PRBC transfusion. If the hematocrit remains low despite transfusion, it could indicate an ongoing issue with blood volume or oxygen delivery to tissues.

A. Determine how the client is administering the medication. B. Advise the client to gargle with warm salt water twice daily. C. Report the client's jaw pain to the healthcare provider. D. Confirm that this is a common symptom of osteoporosis.

Correct Answer is C

Explanation

A. Determine how the client is administering the medication: While the nurse should assess medication administration, jaw pain could be a sign of a serious side effect, and reporting to the healthcare provider is the priority.
B. Advise the client to gargle with warm salt water twice daily: Gargling with salt water may provide some comfort but is not an appropriate solution for jaw pain related to bisphosphonate therapy.
C. Report the client's jaw pain to the healthcare provider: Jaw pain could be a sign of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonates. Immediate reporting is essential.
D. Confirm that this is a common symptom of osteoporosis: Jaw pain is not a common symptom of osteoporosis and should be assessed further.

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

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

Correct Answer is []

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is C

Explanation

Exhibits The nurse reviews the findings in the history and physical. Drag from word choices to complete the sentence. The nurse recognizes that dropdown,dropdown, anddropdownare findings consistent with elder mistreatment.

Which client should the charge nurse on the oncology unit assign to a registered nurse (RN), rather than a practical nurse (PN)?

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the UAP?

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

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.