A client comes into the emergency department with a body temperature of 103°F. It is a hot and humid day, and the client works in a factory with no air conditioning. To help this client, the nurse:
1. Uses warm blankets.
2. Restricts fluids.
3. Assesses vital signs.
4. Applies cool washcloths to the face and neck.
4. Apply cool washcloths to the face and neck.
Rationale:
Until the client has orders written, the nurse can apply cool washcloths to the client's face and neck to increase comfort and reduce the client's body temperature. Warm blankets and fluid restriction would help keep the temperature elevated. Assessing vital signs is important; however, the nurse needs to intervene to help bring the body temperature down.
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Due to increased left atrial pressure, a patient with mitral stenosis often suffers from:
A. Pulmonary congestion B. Hepatomegaly C. Jugular venous distension D. Ventricular tachycardia
Tasks an LPN/LVN delegates to a UAP no longer remain the responsibility of the LPN/LVN
Indicate whether the statement is true or false
A patient is being evaluated for severe burns to the torso and upper extremities, with edema around the burned areas. How should the nurse describe the underlying cause for this assessment finding?
1. inability of the damaged capillaries to maintain fluids in the cell walls 2. reduced vascular permeability in the burned area 3. decreased osmotic pressure in the burned tissue 4. increased fluids in the extracellular compartment
The nurse is preparing a client for discharge from the hospital following a major burn injury. The nurse is developing a plan for his nutrition and understands that:
1. The hypermetabolic state continues until all the wounds are healed. 2. The hypermetabolic state is only present in the emergency and acute periods of burn care. 3. No extra calories are necessary once discharged from the hospital. 4. The calorie intake should be decreased so as not to gain weight.