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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.

Nursing Test Bank

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Correct Answer is B

Explanation

A. A potty chair should be brought from home to maintain the current level of toileting skills: While familiar items can offer comfort, regression in toileting is typically temporary and does not require special equipment to preserve skills.

B. Children usually resume their toileting behaviors when they leave the hospital: Hospitalization is a stressful event for preschoolers, and temporary regression in toileting is common. Reassuring parents that the child is likely to return to previous toileting behaviors once home helps reduce anxiety and supports normal developmental expectations.

C. Diapering will be provided since hospitalization is stressful to preschoolers: Diapering may be used for convenience or safety, but presenting it as necessary for all hospitalized children may cause unnecessary concern. It does not address the expected return to prior skills.

D. A retraining program will need to be initiated when the child returns home: Most children spontaneously resume previous toileting abilities without formal retraining. Only persistent regression after discharge would warrant intervention.

A. Monitor for desquamation and normal flora overgrowth. B. Wash skin between application of topical antiparasitic doses. C. Keep the child's nails short and encourage use of hand mittens. D. Shave the body hair before applying the scabicide lotion.

Correct Answer is C

Explanation

A. Monitor for desquamation and normal flora overgrowth: While monitoring skin integrity is important, this does not directly prevent the primary complication of scabies, which is secondary bacterial infection from scratching.

B. Wash skin between application of topical antiparasitic doses: Washing between doses can remove the medication prematurely, reducing its effectiveness. The lotion should remain on for the prescribed time before being washed off.

C. Keep the child's nails short and encourage use of hand mittens: Trimming nails and using mittens reduce scratching and skin breakdown, which lowers the risk of bacterial superinfection, the main complication of scabies in children.

D. Shave the body hair before applying the scabicide lotion: Shaving is not recommended, as scabicide is effective when applied to the skin surface. Shaving may cause irritation and increase discomfort without improving treatment outcomes.

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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

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

Correct Answer is B

Explanation

The nurse is planning care for a child who is suffering from persistent itching due to scabies. Which measure should the nurse implement to minimize this child's risk for complications?

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.