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    Hesi RN exit proctored examQuestion 47
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    Hesi RN exit proctored exam
    Select All That Apply

    Exhibits The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

    Explanation & Rationale

    A. Check the temperature of the humidified oxygen attached to the ventilator: The client is intubated and receiving humidified oxygen. If the oxygen is cold, it can contribute to hypothermia. Ensuring that the humidified oxygen is at an appropriate temperature will help prevent further heat loss. B. Instill warm fluids in the nasogastric tube: Instilling warm fluids via a nasogastric tube is not a standard or efficient method for core rewarming in a hypothermic trauma client. It introduces a risk of aspiration and is less effective than other core rewarming techniques. C. Microwave a pack of gauze and distribute across the body: Microwaving a pack of gauze is not a safe or controlled method to warm the body. It could result in burns or uneven heat distribution, which could be harmful. D. Place ice packs around the client's head: Ice packs are typically used to lower body temperature, not raise it. Applying ice packs would worsen the hypothermia and is inappropriate in this case. E. Apply warm blankets: Warm blankets are a common and effective method to increase body temperature in hypothermic patients. This will help promote heat retention and stabilize the patient's body temperature. F. Use a fluid warmer for intravenous fluids: Cold intravenous fluids can lower body temperature further. A fluid warmer ensures that fluids are administered at body temperature, helping to prevent hypothermia. G. Administer intravenous fluids with a rapid infuser: While rapid fluid administration is important for hemodynamic stabilization in trauma patients, it does not directly address body temperature. Without a warmer, rapid infusers can contribute to further cooling. H. Administer an antipyretic: Antipyretics are used to reduce fever, but there is no indication that the client has a fever. The concern here is hypothermia, not an elevated temperature, so antipyretics would not be appropriate in this situation.

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