Practice Quiz

NCLEX-PN Exam Practice

Category - Shock

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You are caring for a patient who was brought into the emergency department unresponsive, hypotensive and tachypneic. Upon further assessment, you realize that the patient’s temperature is 106 degrees Fahrenheit. You suspect heat stroke. What would your priority nursing intervention be?
  1. Obtain a history from the patient.
  2. Take oral temperature to monitor effectiveness of treatment.
  3. Call the family for consent to treat.
  4. Take off the patient’s clothing, wrap him or her in wet towels and place a fan on the patient.
Explanation
Answer: D - The nurse’s priority would be to undress and wrap the patient in wet towels and place a fan on him or her. Interventions must be taken quickly to lower the body temperature because heat stroke is life threatening. Core body temperatures should be monitored for effective treatment.
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