On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 ° F (40.1 ° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurs
a. Encourage the client to drink cool water or sports drinks.
b. Start an intravenous line and infuse 0.9% saline solution.
c. Administer acetaminophen (Tylenol) 650 mg orally.
d. Encourage rest and re-assess in 15 minutes.
ANS: B
The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive interventions to cool the client, including external cooling and internal cooling methods. Oral hydration would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not provide necessary rapid rehydration, and the confused client would be at risk for aspiration. Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate.
You might also like to view...
During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response?
A) "Cardioversion is done on a beating heart; defibrillation is not." B) "The difference is the timing of the delivery of the electric current." C) "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D) "Cardioversion is always attempted before defibrillation because it has fewer risks."
If a virus has caused inflammation resulting in endothelial dysfunction, an excessive amount of endothelins in the blood can result in
A) arterial wall weakening resulting in aneurysm formation. B) release of excess fatty plaque causing numerous pulmonary emboli. C) contraction of the underlying smooth muscles within the vessels. D) overproduction of growth factors resulting in new vessel production.
Patients bring a wide variation in their capacity to use information technology. Which of the following does not increase the usability of PHRs?
1. Easy navigation 2. Simple functionality 3. Decreased e-literacy 4. Readability
When asked by a patient's family how core temperature differs from tympanic temperature, a nurse says:
1. "A tympanic temperature is obtained using sterile technique and is more time consuming." 2. "Taking the core temperature is more reflective of the environment the internal organs are being exposed to." 3. "Obtaining a core temperature far outweighs the benefits of a tympanic temperature because it is less invasive." 4. "Taking a tympanic temperature is uncomfortable and more invasive."