Your patient was outdoors and developed hypothermia.
You know that independent nursing interventions would include:
Soaking extremities in hot water.
Administering warmed intravenous fluids.
Administering hot whirlpool therapy.
Replacing wet clothing with dry clothing.
The Correct Answer is D
Replacing wet clothing with dry clothing is an independent nursing intervention that can help prevent further heat loss and gradually warm the patient. Soaking extremities in hot water (choice A) is not recommended because it can cause vasodilation and hypotension. Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiac dysrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is an example of secondary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complications. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.
A client who has a family history of breast cancer and is scheduled for a mammogram is an example of secondary prevention. Secondary prevention is early detection of a disease before it progresses. Secondary prevention can include screenings and other forms of diagnostic tests.
This is an example of tertiary prevention, which is the action taken to stop the progress of the disease at the initial stage and prevent complication. An echocardiogram can help diagnose the severity and cause of heart failure and guide the treatment plan.
Choice C is wrong because it is not an example of any level of prevention.
A client who is asymptomatic is not scheduled for a series of tests because there is no indication of any disease or risk factor.
Choice D is wrong because it is an example of primary prevention, which is the action taken to prevent the development of disease.
A client who is scheduled to receive an influenza vaccination is protected from getting infected by the virus and developing flu-related complications.
Correct Answer is D
Explanation
The nurse has a duty to protect the patient’s rights and well-being, and to report any signs of abuse or neglect. Financial abuse is defined as someone illegally or improperly using an elder’s money or belongings for their own personal use. It is a common form of elder abuse and can have serious consequences for the victim’s physical and mental health.
The nurse should not assume that the son has the patient’s best interest in mind (choice A), as this may not be the case.
The nurse should not ignore the situation or dismiss it as a non-clinical issue (choice B), as this would violate the nurse’s ethical and legal obligations. The nurse should not notify the primary care physician that the patient can no longer care for himself (choice C), as this may not be true and may infringe on the patient’s autonomy and dignity.
The nurse should respect the patient’s wishes and help him to exercise his rights and choices.
The nurse should also provide support and resources to the patient, such as counselling, legal aid, or social services.
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