Difficulty: Medium
Average Score: 71%
Simulated
An unresponsive 79-yr-old patient 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) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?
Correct answer
C
Rationale
Applying wet sheets and a fan to the patient is the most critical initial action. This method facilitates rapid evaporative cooling, which is essential for quickly reducing the dangerously high core body temperature in severe heat stroke. Prompt cooling is paramount to prevent irreversible organ damage and improve patient outcomes in this life-threatening emergency.
A: Give acetaminophen (Tylenol) rectal suppository. Antipyretics like acetaminophen are ineffective in treating heat stroke because the hyperthermia is not mediated by the hypothalamic set-point. Furthermore, rectal absorption is slow and unreliable in this critical condition, delaying crucial cooling efforts.
B: Provide O2 at 2 L/min with a nasal cannula. While oxygen support may be indicated for respiratory distress or hypoxia, it does not address the primary, life-threatening issue of severe hyperthermia and circulatory collapse. Rapid cooling takes immediate priority over oxygen administration in this scenario.
D: Start lactated Ringer's solution at 1000 mL/hr. Fluid resuscitation is important for hypotension and dehydration associated with heat stroke, but it is secondary to immediate, aggressive cooling. The most urgent action is to lower the patient's core temperature to prevent further organ damage; fluids can be initiated concurrently, but cooling is the primary intervention.
A: Give acetaminophen (Tylenol) rectal suppository. Antipyretics like acetaminophen are ineffective in treating heat stroke because the hyperthermia is not mediated by the hypothalamic set-point. Furthermore, rectal absorption is slow and unreliable in this critical condition, delaying crucial cooling efforts.
B: Provide O2 at 2 L/min with a nasal cannula. While oxygen support may be indicated for respiratory distress or hypoxia, it does not address the primary, life-threatening issue of severe hyperthermia and circulatory collapse. Rapid cooling takes immediate priority over oxygen administration in this scenario.
D: Start lactated Ringer's solution at 1000 mL/hr. Fluid resuscitation is important for hypotension and dehydration associated with heat stroke, but it is secondary to immediate, aggressive cooling. The most urgent action is to lower the patient's core temperature to prevent further organ damage; fluids can be initiated concurrently, but cooling is the primary intervention.