Nokea
The nurse is caring for an older adult in the emergency department with moderate hypothermia. Which of the following actions should the nurse take? Select all that apply.
- A. Apply external heat with a heating blanket to the client's trunk.
- B. Actively rewarm the extremities first, followed by the client's trunk.
- C. Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis.
- D. Monitor for fluid, electrolyte, and metabolic abnormalities.
- E. Administer ordered medications at spaced longer intervals.
- F. Administer room temperature intravenous (IV) fluids for core rewarming.
Correct Answer: A,D,F
Rationale: Applying heat to the trunk (A), monitoring electrolytes (D), and using room-temperature IV fluids (F) are appropriate for moderate hypothermia. Rewarming extremities first (B) risks core afterdrop, extracorporeal methods (C) are for severe cases, and altering medication intervals (E) lacks evidence.
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Clients who have had active tuberculosis are at risk for recurrence. Which of the following conditions increases that risk?
- A. Cool and damp weather.
- B. Active exercise and exertion.
- C. Physical and emotional stress.
- D. Rest and inactivity.
Correct Answer: C
Rationale: Physical and emotional stress can weaken the immune system, increasing the risk of tuberculosis recurrence. Weather, exercise, and rest do not directly influence recurrence.
A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
- A. Assess for GI bleeding.
- B. Hold the Lactulose (Cephulac).
- C. Increase protein in the diet.
- D. Monitor serum bilirubin levels.
Correct Answer: A
Rationale: Confusion and asterixis indicate hepatic encephalopathy, often precipitated by GI bleeding (A), which increases ammonia levels. Holding lactulose (B) is incorrect as it reduces ammonia. Increasing protein (C) worsens encephalopathy. Bilirubin (D) is unrelated to acute symptoms.
A client uses timolol maleate (Timoptic) eyedrops. The expected outcome of this beta-adrenergic blocker is to control glaucoma by:
- A. Constricting the pupils.
- B. Dilating the canals of Schlemm.
- C. Reducing aqueous humor formation.
- D. Improving the ability of the ciliary muscle to contract.
Correct Answer: C
Rationale: Timolol maleate, a beta-adrenergic blocker, reduces intraocular pressure by decreasing the production of aqueous humor in the eye.
The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first to last, should the nurse complete the following tasks?
- A. Verify the client has signed an informed consent.
- B. Position the client in a side-lying position.
- C. Clean the skin with an antiseptic solution.
- D. Apply ice to the biopsy site.
Correct Answer: C,A,B,D
Rationale: First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins, and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should clean the skin site and surrounding area with an antiseptic solution such as Betadine before the health care provider collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.
The nurse is planning care for a client with a fractured humerus in a sling. Which intervention should be included?
- A. Encourage shoulder shrugging exercises.
- B. Apply heat to the fracture site.
- C. Keep the arm in a dependent position.
- D. Restrict all arm movement.
Correct Answer: A
Rationale: Shoulder shrugging exercises maintain mobility and prevent stiffness without stressing the fracture.