An unresponsive 79-year-old is admitted to the emergency ...

[APUS57]

An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4 F (40.8 C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to
 
  a. apply wet sheets and a fan to the patient.
  b. provide O2 at 6 L/min with a nasal cannula.
  c. start lactated Ringer's solution at 1000 mL/hr.
  d. give acetaminophen (Tylenol) rectal suppository.

Question 2

A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
 
  a. Heart rate
  b. Breath sounds
  c. Body temperature
  d. Level of consciousness

[mcarey591]

Answer to Question 1

ANS: A
The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke, and 100 oxygen should be given, which requires a high flow rate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

Answer to Question 2

ANS: B
The priority assessment relates to ABCs (airway, breathing, circulation) and how well the patient is oxygenating, so breath sounds should be assessed first. The other data will also be collected rapidly but are not as essential as the breath sounds.

[APUS57]

TYSM

[laurnthompson]

Excellent