The home health nurse in Wyoming gives instruction to an 80-year-old patient in the prevention of hypothermia.
Which information should the nurse include? (Select all that apply.)
Wear multiple layers of clothing.
Drink warm fluids from a thermos.
Wear gloves and earmuffs.
Wear a loose-fitting hat.
Correct Answer : A,B,C,D
Choice A rationale
Wearing multiple layers of clothing helps to trap body heat, preventing hypothermia.
Choice B rationale
Drinking warm fluids from a thermos helps maintain body temperature by providing warmth.
Choice C rationale
Wearing gloves and earmuffs prevents heat loss from extremities, which is essential in preventing hypothermia.
Choice D rationale
Wearing a loose-fitting hat prevents heat loss from the head, which is a significant source of body heat loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale: Oral health indicates the absence of mucositis or other oral complications, which is good, but it doesn't necessarily reflect overall improvement in the client's cancer or chemotherapy response.
Choice B rationale: The absence of bleeding episodes is significant. This suggests that the client's platelet count has improved, reducing the risk of bleeding, which is an important indicator of recovery.
Choice C rationale: While weight maintenance or gain can be an indicator of health improvement, the slight decrease in weight from January to February (70.5 kg to 69 kg) does not suggest an improvement.
Choice D rationale: An increase in the WBC count to within the normal range (4.2 x 10⁹/L) is a positive sign. It indicates that the client’s immune system is recovering, which is crucial during chemotherapy.
Choice E rationale: The improvement in platelet count to within the normal range (150 x 10⁹/L) suggests a reduced risk of bleeding and reflects better bone marrow function, which is a positive outcome of the treatment.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale: Contact precautions are not necessary in this situation as the client is presenting symptoms of a possible infection related to chemotherapy-induced immunosuppression, not a contagious disease.
Choice B rationale: Placing the client in a private room is crucial to protect her from potential infections, given her compromised immune system due to chemotherapy.
Choice C rationale: Encouraging the client to increase fluid intake can help manage fever and muscle aches and keep her hydrated, which is important when dealing with symptoms of infection and fatigue.
Choice D rationale: Wearing a mask when caring for the client is necessary to protect both the client and the healthcare provider from potential infections, considering the client’s immunocompromised state.
Choice E rationale: Preparing to administer an antibiotic should be based on the healthcare provider's orders and further diagnostic results. While it might be necessary, it is not an immediate nursing action without provider confirmation.
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