The ED nurse has admitted a client who is homeless and was found unresponsive in the street during below freezing temperatures. The client is diagnosed with severe hypothermia. The nurse should implement which measures for this client?
Rationale: The client’s level of consciousness must be assessed as part of a standard admission assessment, as it will determine treatments needed. The client is placed supine to avoid orthostatic alterations in blood pressure due to cardiac instability. The client should be handled gently to prevent ventricular fibrillation. The nurse should administer CPR if the client does not have spontaneous circulation. Heating blankets are contraindicated in severe hypothermia; the treatment of choice is extracorporeal rewarming via cardiopulmonary bypass or hemodialysis. A rectal temperature is the most accurate in the hypothermic client. Massaging the extremities may injure frostbitten extremities and should not be performed.
