Chapter 09: Care of Patients with Common Environmental Emergencies Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 56

1. 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 nurse take? 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-assessin 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 clients temperature or improve the clients symptoms. The client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is inappropriate. DIF: Applying/Application REF: 134 KEY: Heat-related illness| environmental emergencies MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first? a. Elevate the site and notify the persons next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911. ANS: D The clients swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency. 911 should be called immediately, and the client transported to the emergency department as quickly as possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction. The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis. DIF: Applying/Application REF: 142 KEY: Bee and insect sting| anaphylaxis| environmental emergencies MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A client presentsto the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first? a. Reposition the client into a prone position. b. Administer warmed intravenous fluids to the client. c. Wrap the clients extremities in warm blankets. d. Initiate extracorporeal rewarming via hemodialysis. ANS: B Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to prevent orthostatic changes. The clients trunk should be warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia. Downloaded by: jamiegifford | Distribution of this document is illegal Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman