The nurse is caring for an unconscious patient who was just pulled from a freezing lake. What is the priority action of the nurse?
Have the patient drink hot liquids.
Bathe the patient to promote shivering
Remove restrictive items of clothing.
Wrap the patient in warmed blankets.
The Correct Answer is D
A. Have the patient drink hot liquids. An unconscious patient cannot safely swallow, and forcing fluids could lead to aspiration. Additionally, internal warming should be done cautiously to avoid complications like shock.
B. Bathe the patient to promote shivering. Shivering is the body’s natural response to generate heat, but bathing a hypothermic patient would further lower body temperature and worsen the condition.
C. Remove restrictive items of clothing. While removing wet or restrictive clothing is important, it is not the priority over actively warming the patient. Hypothermia management focuses on gradual rewarming.
D. Wrap the patient in warmed blankets. The priority in hypothermia is gradual external rewarming using warmed blankets to prevent further heat loss and safely increase body temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the patient to rate the pain on a 0-to-10 scale. Pain is subjective, and the first step in pain management is assessment. Asking the patient to rate their pain helps determine the severity and whether adjustments to pain management are needed.
B. Call the physician or health care provider immediately. Contacting the provider may be necessary if the pain is uncontrolled, but the nurse must assess the pain level first before deciding if intervention is needed.
C. Check the patency of the patient's intravenous line. While an IV line is essential for PCA function, the priority is assessing the patient’s pain level before troubleshooting the equipment.
D. Speak to the patient in a calming tone to reduce anxiety. Although a calm demeanor is beneficial, it does not address the patient’s pain directly. Pain assessment is the first priority.
Correct Answer is A
Explanation
A. Falsely low. Using an adult-sized cuff on a child results in an overestimation of the cuff size, causing the cuff to not inflate properly and distribute less pressure, leading to a falsely low blood pressure reading.
B. Indistinct. The reading may be inaccurate, but it will still produce a numerical value rather than being completely indistinct.
C. Accurate. Accuracy depends on using a cuff size appropriate for the child's arm circumference. An adult cuff on a child is too large, leading to an incorrect reading.
D. Falsely high. A too-small cuff would produce a falsely high reading, but an oversized cuff produces a falsely low blood pressure.
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