Author Question: The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been ... (Read 31 times)

ARLKQ · **on:** Jun 25, 2018

The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest.

Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
a. Continuously monitor heart rhythm.
b. Check neurologic status every 2 hours.
c. Place cooling blankets above and below patient.
d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
e. Insert rectal temperature probe and attach to cooling blanket control panel.

Question 2

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?

a. Use tweezers to remove any remaining ticks.
b. Check the vital signs, including temperature.
c. Give doxycycline (Vibramycin) 100 mg orally.
d. Obtain information about recent outdoor activities.

paavo · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C, D, E
Experienced LPN/LVNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and administer medications under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN.

Answer to Question 2

ANS: A
Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release.