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
A lack of insurance or lack of sufficient insurance is a huge barrier in accessing health care. According to the Kaiser Family Foundation, uninsured people are less likely to receive preventive care and services for major health conditions and chronic diseases. They also face greater difficulties in affording care and paying medical bills.
Choice B is wrong because politics is not the only factor that affects the availability and affordability of health insurance. Other factors include income, employment status, age, health status, and geographic location. Nurses have a professional and ethical responsibility to advocate for the health needs of their clients and communities, which may involve engaging with political issues. Choice C is wrong because language is not the only problem for uninsured or underinsured clients. Other problems include cost, access, quality, and continuity of care. Language barriers may affect communication and understanding between clients and providers, but they can be addressed by using interpreters, translators, or culturally competent staff.
Choice D is wrong because the Joint Commission does not regulate insurance coverage. The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations and programs in the United States. It sets standards for quality and safety of care, but it does not determine who is eligible for insurance or what benefits are covered.
Correct Answer is C
Explanation
his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.
Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.
Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.
Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.
Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.
Normal ranges for skin integrity are:
• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.
• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.
• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.
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