a nurse is caring for a client who has hyperthermia which of the following actions should the nurse take
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020 Answers

1. A client has hyperthermia. Which of the following actions should the nurse take?

Correct answer: C

Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.

2. How should a healthcare provider care for a patient with a nasogastric (NG) tube?

Correct answer: A

Rationale: When caring for a patient with a nasogastric (NG) tube, it is crucial to check the tube placement and assess for signs of aspiration. This ensures that the tube is correctly positioned and that the patient is not at risk of complications such as aspiration pneumonia. Choice B is incorrect as flushing the tube with water regularly is not a standard practice and may not be appropriate for all patients. Choice C is incorrect as monitoring for bowel sounds is not directly related to NG tube care, and administering medications is not the primary focus of caring for the tube itself. Choice D is incorrect because administering medications through the NG tube is a specific action that may be taken based on a healthcare provider's order, not a general care guideline for the NG tube.

3. What are the signs of hypoglycemia, and how should they be managed?

Correct answer: A

Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.

4. A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Correct answer: C

Rationale: The correct answer is C: 'Lack of sleep.' In a client experiencing acute mania due to bipolar disorder, lack of sleep is the priority finding for the nurse to address. Sleep deprivation can exacerbate symptoms, lead to exhaustion, and increase the risk of further complications. Pressured speech, increased appetite, and mood swings are also common in acute mania, but addressing the lack of sleep takes precedence due to its significant impact on the client's well-being and recovery.

5. How should a healthcare professional manage a patient with a tracheostomy?

Correct answer: A

Rationale: Correct answer: Monitoring airway patency and providing humidified oxygen is crucial in managing a patient with a tracheostomy to ensure proper breathing and oxygenation. Ensuring the airway is clear and providing oxygen support are immediate priorities. Providing education on tracheostomy care (Choice B) is important for long-term management but not the immediate priority. Suctioning airway secretions and changing tracheostomy ties (Choice C) are tasks that may be necessary but do not address the primary concern of maintaining airway patency. Providing a high-protein diet and ensuring fluid restriction (Choice D) are unrelated to the immediate management of a tracheostomy.

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