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
Watching television until falling asleep at night is a poor sleep habit because it can interfere with the body’s natural sleep-wake cycle and make it harder to fall asleep and stay asleep. Television can also expose the eyes to bright light and stimulating or stressful content, which can affect the production of melatonin, a hormone that regulates sleep.
Choice B is wrong because having a small snack and taking a bath before going to bed each day are good sleep habits that can promote relaxation and sleep quality.
Choice C is wrong because not taking naps throughout the day is a good sleep habit that can help maintain a consistent sleep schedule and avoid disrupting the night-time sleep.
Choice D is wrong because going to bed and getting up at the same times each day is a good sleep habit that can reinforce the body’s circadian rhythm and make it easier to fall asleep and wake up.
Correct Answer is ["A","B","C"]
Explanation
These actions ensure the safety of the client by reducing the risk of falls, confusion and injury.
Keeping a call bell within the client’s reach allows them to ask for help when needed.
Keeping a dim light on at night helps them orient themselves and see their surroundings.
Keeping unnecessary furniture out of the way prevents tripping and cluttering. Choice D is wrong because keeping all side rails up at all times can be considered a form of physical restraint, which is associated with many professional, legal and ethical challenges. Physical restraint should only be used as a last resort when other alternatives have failed or are not feasible. Keeping all side rails up can also increase the risk of injury if the client tries to climb over them.
Choice E is wrong because keeping all lights off at night can increase the risk of falls and confusion for the client.
Older adults may have impaired vision and cognition, and they may need to use the bathroom frequently at night. Keeping all lights off can make it difficult for them to find their way and increase their anxiety.
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