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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 A

Explanation

A. Hydrocortisone: The client is experiencing an Addisonian (adrenal) crisis, evidenced by weakness, confusion, dehydration, hyponatremia, hyperkalemia, and hypoglycemia. Intravenous hydrocortisone provides the deficient cortisol necessary to stabilize electrolytes, improve vascular tone, and support glucose regulation.

B. Potassium chloride: Although the client’s potassium is elevated, administering potassium would worsen hyperkalemia. The priority is treating the underlying adrenal insufficiency rather than directly correcting potassium at this stage.

C. Broad spectrum antibiotic: There is no evidence of a bacterial infection causing the crisis; the client’s acute illness is a viral infection, and antibiotics would not address adrenal insufficiency. Antibiotics may be considered only if a bacterial infection is confirmed.

D. Regular insulin: Insulin lowers blood glucose and potassium, but this client is hypoglycemic and hyperkalemic due to adrenal crisis. Administering insulin would exacerbate hypoglycemia and is contraindicated in this scenario.

Correct Answer is ["0.6"]

Explanation

Calculation:

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

The client's weight is 154 lb.

Client weight (kg) = 154lb/2.2lb/kg

= 70kg.

Calculate the total dose to be administered (units).

The ordered dose is 200 units/kg.

Total dose (units) = 200units/kg×70kg

= 14,000units.

Calculate the volume to administer in milliliters (mL).

Available concentration is 25,000units/mL.

Volume (mL) = Totaldose(units)/Availableconcentration(units/mL)

= 14,000units/25,000units/mL

= 0.56mL.

Round the answer to the nearest tenth.

= 0.6mL.

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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 A

Explanation

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.6"]

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.