Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?
The patient develops atrial fibrillation.
The core temperature is 94° F (34.4" C).
The BP decreases to 86/42 mm Hg.
The patient begins to shiver
The Correct Answer is B
A. Developing atrial fibrillation can be a complication of hypothermia, but rewarming is still necessary to address the underlying condition.
B. Active rewarming should be discontinued if the patient's core temperature reaches 94°F (34.4°C), as further active rewarming could lead to complications. It's important to transition to passive rewarming methods to allow the patient's temperature to normalize gradually.
C. A decrease in blood pressure may indicate hypovolemia or shock but does not necessarily require discontinuation of rewarming.
D. Shivering is a normal response during rewarming and does not indicate a need to discontinue rewarming efforts unless other complications arise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This client has respiratory distress but is conscious and stable, requiring urgent but not immediate attention compared to other critical conditions.
B. This client has a dislocated shoulder, which is painful and needs attention but is not life-threatening compared to other conditions.
C. This client is unconscious with a sucking chest wound and high respiratory rate, indicating severe respiratory compromise and needing immediate intervention to prevent further deterioration.
D. This client is also unconscious with no respirations despite attempted airway management, indicating a need for immediate resuscitative efforts, potentially including CPR.
Correct Answer is C
Explanation
A. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Clients undergoing stem cell transplants are immunocompromised due to chemotherapy and conditioning regimens. To reduce the risk of infection, all equipment that comes into contact with the client, such as blood pressure cuffs, should be dedicated to that room only. This prevents cross-contamination from other patients.
D. Negative pressure rooms are for protecting others from airborne infections (e.g., TB). Stem cell transplant clients require positive pressure rooms to protect them from pathogens in the environment.
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