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

Answer and Explanation

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.

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Correct Answer is D

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. Keeping blood pressure equipment in the client's room is necessary but does not directly address infection control, which is critical in stem cell transplant recipients.
D. Placing the client in a negative airflow room is crucial to reduce the risk of infections, which are a major concern in immunocompromised clients undergoing stem cell transplantation.

A. A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min B. A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky. C. An unconscious adult client who has a large head wound with gray matter exposed; absent respirations D. An unconscious 6-month-old infant with no respirations, no visible injuries

Correct Answer is C

Explanation

A. This client has significant burns but is conscious and breathing, indicating adequate airway and respiratory effort.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C. This client is unconscious with a severe head injury and absent respirations, indicating a compromised airway and immediate life-threatening condition.
D. This infant is unconscious with no respirations, requiring immediate attention but is not as urgent as the client with the severe head injury and compromised airway.

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Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia?

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Naxlex Comprehensive Predictor Exams

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