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Patient Data

Exhibits

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

Apply warm blankets

Administer an antipyretic

Place ice packs around the client's head

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Microwave a pack of gauze and distribute across the body

Administer intravenous fluids with a rapid infuser

Use a fluid warmer for intravenous fluids

Answer and Explanation

Correct Answer : A,D,E,G,H

A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.

B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.

C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.

D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.

E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.

F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.

G. Administer intravenous fluids with a rapid infuser: Warm IV fluids given rapidly restore circulating volume in trauma clients and also help increase core body temperature, addressing both shock and hypothermia.

H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.

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Correct Answer is ["18"]

Explanation

Calculation:

Convert the client's weight from pounds (lb) to kilograms (kg).

The client's weight is 220 lb.

Client weight (kg) = 220lb/2.2lb/kg

= 100kg.

Calculate the total heparin dose to be administered per hour (units/hr).

The ordered rate is 18 units/kg/hour.

Total dose rate (units/hr) = 18units/kg/hour×100kg

= 1800units/hr.

Determine the concentration of the available solution (units/mL).

Available solution is 25,000units in 250mL.

Concentration (units/mL) = 25,000units/250mL

= 100units/mL.

Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Totaldoserate(units/hr)/Concentration(units/mL)

= 1800units/hr/100units/mL

= 18mL/hr.

A. Use nasal or cough tissues followed by handwashing at all times. B. Ensure supplemental oxygen and respiratory medications are available at all times. C. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines. D. Avoid large crowed areas during the colder months of the year.

Correct Answer is C

Explanation

A. Use nasal or cough tissues followed by handwashing at all times: Hand hygiene and respiratory etiquette are important to reduce infection risk, but they are general preventive measures and not as critical as vaccination for high-risk clients with chronic respiratory diseases.

B. Ensure supplemental oxygen and respiratory medications are available at all times: Having medications and oxygen ready is important for managing acute symptoms, but it does not prevent illness or complications; it is part of ongoing disease management not prevention.

C. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines: Vaccination is the most important preventive measure for clients with asthma, chronic bronchitis, or emphysema. These clients are at higher risk for respiratory infections, which can cause severe exacerbations, hospitalization, and complications.

D. Avoid large crowded areas during the colder months of the year: Limiting exposure can reduce infection risk but is a situational preventive measure. Vaccination provides broader and more effective protection against common respiratory pathogens.

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Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["18"]

Explanation

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

Correct Answer is C

Explanation

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Patient Data

Exhibits

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