The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism.
Which nursing intervention is done to prevent heat loss by conduction?

Closing doors and windows to prevent draft (current of air with motion).

Keeping a hat on the baby’s head.

Thoroughly drying infant after a bath.

Placing a warm blanket on the scale prior to obtaining baby’s weight.

Answer and Explanation

The Correct Answer is D

This is because heat loss by conduction occurs when two objects with different temperatures come into direct contact with each other. The baby’s skin would lose heat to the cold scale by conduction if there was no warm blanket between them.

Choice A is wrong because closing doors and windows to prevent draft (current of air with motion) would prevent heat loss by convection, not conduction. Convection is the transfer of heat from a body to moving molecules such as air or liquid.

Choice B is wrong because keeping a hat on the baby’s head would prevent heat loss by radiation, not conduction. Radiation is the transfer of heat from a body to the surroundings by electromagnetic waves.

Choice C is wrong because thoroughly drying infant after a bath would prevent heat loss by evaporation, not conduction. Evaporation is the process of liquid changing into gas and carrying away heat from the body surface.

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Correct Answer is D

Explanation

This is the nurse’s priority because it will help determine the severity of the client’s difficulty breathing and guide the appropriate interventions. According to the Mayo Clinic, oxygen therapy for COPD is indicated when there is not enough oxygen in the blood, which can be measured by a pulse oximeter or a blood gas test. Increasing the oxygen flow without assessing the oxygen level could be harmful or ineffective. Having the client cough and expectorate secretions may help clear the airway, but it is not the first action to take. Calling emergency services may be necessary if the client’s condition is life threatening, but it should not be done before assessing the respiratory status.

Choice A is wrong because it does not address the immediate need of assessing the respiratory status and may cause unnecessary panic or delay in treatment.

Choice B is wrong because it does not follow the guidelines for oxygen therapy for COPD, which require a prescription and monitoring of oxygen levels.

Increasing the oxygen flow without assessing the oxygen level could cause oxygen toxicity or suppress the respiratory drive.

Choice C is wrong because it is not the most urgent action to take.

Having the client cough and expectorate secretions may help clear the airway, but it may also increase the work of breathing and worsen hypoxia.

Assessing the respiratory status should come first.

Normal ranges for oxygen saturation are 95% to 100% for healthy individuals and 88% to 92% for most people with COPD. Normal ranges for blood gas tests vary depending on the laboratory, but generally, normal values for arterial blood gas are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, PaO2 80 to 100 mm Hg, HCO3 22 to 26 mEq/L.

A. Left lower quadrant. B. Left upper quadrant. C. Right upper quadrant. D. Right lower quadrant.

Correct Answer is D

Explanation

McBurney’s point is located one-third of the distance from the right anterior superior iliac spine to the umbilicus. This is where the base of the appendix is attached to the cecum, which is part of the large intestine. When the appendix becomes inflamed or infected, it causes pain in this area.

Choice A is wrong because the left lower quadrant is where the sigmoid colon and part of the small intestine are located.

These organs are not related to appendicitis.

Choice B is wrong because the left upper quadrant is where the stomach, spleen, and part of the pancreas are located.

These organs are also not related to appendicitis.

Choice C is wrong because the right upper quadrant is where the liver, gallbladder, and part of the small intestine are located. These organs can cause pain in this area if they have problems, but not appendicitis

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The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism. Which nursing intervention is done to prevent heat loss by conduction?

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Naxlex Comprehensive Predictor Exams

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse’s priority?

Correct Answer is D

Explanation

In individuals who have appendicitis, the pain will typically localize to McBurney’s point. Which quadrant of the abdomen is McBurney’s point found?

Correct Answer is D

Explanation

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The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism.
Which nursing intervention is done to prevent heat loss by conduction?