Medical Surgical Critical Care Hypothermia & Frostbite #2

Question

A client was brought to the emergency department by EMS and the client had been submerged into a pond that was iced over for 1 hour. The client’s pulses are weak and thready, has wheezing bilaterally, with crackles in the base of both lungs. Which intervention is priority for the nurse?

Answers

  1. Remove the client's wet clothes and cover with dry clothes & warm blankets.
    • Rationale:

      This answer is correct because the client’s wet clothing should be removed and dry clothing put on the client and then warm blankets applied.

  2. Cover the client with warm blankets and a heating pad.
    • Rationale:

      This answer is not correct because covering the client with warm blankets and a heating pad over their wet clothes does not help with warming the body’s core temperature, plus could electrocute the client with wet clothes and an electrical heating pad.

  3. Remove the client's wet clothes and place the client in a hot bath.
    • Rationale:

      This answer is not correct because although it is best to remove the client’s wet clothes, placing the client in a hot bath is contraindicated for a client with severe hypothermia. If the client had mild hypothermia, with supervision, the client could be placed in a hot bath.

  4. Administer pain and nausea medications to the client.
    • Rationale:

      This answer is not correct because the question does not mention that the client is experiencing pain or nausea, so this would not be the priority intervention.

Overview

Hypothermia is when the core body temperature is < 95ºF. The nurse needs to handle the client with care. Nursing interventions are mechanical ventilation, cardiac monitoring with defibrillation, rewarming the client’s trunk and then the extremities, and administering warmed IV fluids with 2 large bore IVs.

Explanation

Learning Outcomes

Hypothermia is when the core body temperature is < 95ºF. The nurse needs to handle the client with care. The client’s wet clothing should be removed and dry clothing put on the client and warm blankets applied. Always warm the trunk first, then the extremities. Nursing interventions are mechanical ventilation, cardiac monitoring with defibrillation, rewarming the client’s trunk and then the extremities, and administering warmed IV fluids with 2 large bore IVs.

Test Taking Tip

Know the differences in mild and severe hypothermia and the priority interventions for each.

Video Rationale