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 C
Explanation
Choice A rationale
Metabolic acidosis can occur in renal failure but is not directly linked to tumor lysis syndrome.
Choice B rationale
Elevated white blood cell count is not a primary contributor to renal failure in tumor lysis syndrome.
Choice C rationale
Crystallization of uric acid in the renal tubules can obstruct urine flow and cause acute renal failure, which is a direct pathophysiologic event in tumor lysis syndrome.
Choice D rationale
Hypocalcemia is a consequence of tumor lysis syndrome but does not directly cause renal failure.
Correct Answer is C
Explanation
Choice A rationale
Providing articles from the Internet may not always be reliable and might overwhelm or confuse the client, especially at an emotionally sensitive time.
Choice B rationale
While reassuring the client is important, simply assuring them that the provider will explain later does not empower the client to be actively involved in their care.
Choice C rationale
Encouraging the client to write down questions helps them take an active role in their treatment planning, ensures they remember their concerns, and facilitates a more productive conversation with the provider.
Choice D rationale
Suggesting the client wait for the next appointment can increase anxiety and leave the client feeling unsupported during a critical time when they need information and emotional support.
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