On a hot humid day, a nurse is caring for a client who is confused and presents with these vital signs: temperature 104.1°F (40.1°C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mmHg.
What action would the nurse take to provide immediate appropriate care?
Encourage the client to drink cool water or sports drinks.
Administer acetaminophen 650 mg orally.
Start an intravenous line and infuse 0.9% saline solution.
Encourage rest and reassess in 15 minutes.
The Correct Answer is C
Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
An RBC count of 5 million/mm³ is within the normal range for adult females, so this finding would not be concerning in the context of chemotherapy.
Choice B rationale
A WBC count of 2300/mm³ is significantly lower than the normal range (typically 4500 to 11000/mm³) and indicates neutropenia, which is a critical side effect of chemotherapy that needs to be reported immediately.
Choice C rationale
Hemoglobin level of 12 g/dL is within the normal range for adult females, so this would not be concerning in the context of chemotherapy.
Choice D rationale
A platelet count of 155,000/mm³ is within the normal range (150,000 to 450,000/mm³). Although on the lower end, it is not typically alarming enough to report immediately in the context of chemotherapy.
Correct Answer is C
Explanation
Choice A rationale
Systemic lupus erythematosus (SLE) does not originate in the peripheral vascular system. This system involves the blood vessels outside of the heart and brain, and while SLE can affect these vessels, it is not the primary origin of the disease.
Choice B rationale
SLE does not originate in muscle tissue. Muscle involvement in SLE typically results from inflammation caused by the autoimmune response, but muscle tissue is not the source of the disease.
Choice C rationale
Connective tissue is where SLE originates. SLE is an autoimmune disease that primarily targets connective tissue, causing inflammation and damage to various organs and systems throughout the body.
Choice D rationale
The lymphatic system is not the origin of SLE. While the immune system plays a key role in SLE, the disease itself originates in the connective tissue, not the lymphatic system.
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