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 C
Explanation
A. Always take the patient's blood pressure manually using a sphygmomanometer. While manual BP measurements can be more accurate, they are not the priority intervention for orthostatic hypotension, which primarily involves position changes and fall prevention.
B. Monitor the patient's neurological status carefully for symptoms of a stroke. Orthostatic hypotension can cause dizziness or fainting, but it is not a direct cause of stroke. Neurological assessment is important if symptoms arise but is not the primary intervention.
C. Assist the patient to sit and stand slowly when getting out of bed. Orthostatic hypotension causes a sudden drop in blood pressure upon standing, increasing the risk of falls and syncope. The priority action is to help the patient transition slowly from lying to sitting and standing to allow the body to adjust.
D. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff. Lower extremity BP measurements are not standard for managing orthostatic hypotension. Blood pressure should be checked in both lying, sitting, and standing positions to monitor for significant drops.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.