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A nurse is caring for a 40-year-old male client in the postanesthesia care unit (PACU) following abdominal surgery.

Exhibits

Complete the following sentence by using the list of options provided.

The nurse should first address the client’s:

followed by

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

The nurse should first address the client’s elevated temperature followed by administering fluids.

So, the complete sentence would be: The nurse should first address the client’s elevated temperature followed by administering fluids.

Certainly! Let’s break down the situation and the rationale behind the priorities:

Elevated Temperature

The client’s temperature spiked significantly from 36.7°C (98.1°F) to 40.2°C (104.4°F) within a short period. This rapid increase is concerning for several reasons:

  1. Risk of Hyperthermia: A temperature of 40.2°C is dangerously high and can lead to hyperthermia, which can cause damage to body tissues and organs if not promptly addressed.
  2. Signs of Infection or Sepsis: Such a high fever could indicate a postoperative infection or sepsis, both of which require immediate attention.
  3. Physiological Stress: Elevated temperatures increase metabolic demands, which can exacerbate other symptoms like tachycardia (high heart rate) and hypotension (low blood pressure).

Administering Fluids

After addressing the elevated temperature, the next priority is to administer fluids. Here’s why:

  1. Hypotension (Low Blood Pressure): The client’s blood pressure dropped from 110/75 mm Hg to 90/60 mm Hg. This hypotension could be due to several factors, including dehydration, fever, or a systemic inflammatory response.
  2. Tachycardia (High Heart Rate): The client’s heart rate increased from 65/min to 125/min. This could be a compensatory mechanism for the low blood pressure or a response to the fever. Administering fluids can help stabilize the blood pressure and reduce the heart rate.
  3. Preventing Shock: Ensuring adequate fluid volume is crucial to prevent hypovolemic shock, which can occur if the body loses too much fluid or blood.

Immediate Actions Taken

The nurse already administered acetaminophen and applied ice packs to help reduce the fever, which are appropriate initial steps. However, continuous monitoring and additional interventions, such as fluid administration, are necessary to stabilize the client’s condition.

Summary

In summary, the nurse should first address the client’s elevated temperature to prevent potential complications from hyperthermia and then administer fluids to stabilize blood pressure and heart rate. This approach prioritizes the most immediate threats to the client’s health and ensures a comprehensive response to the symptoms presented.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Here are the indications for each teaching statement:

  1. “It is expected for your stools to be black while taking this medication.”
    • Indicated: This is a common side effect of iron supplements like ferrous sulfate.
  2. “Take this medication with an antacid if you experience heartburn from the medication.”
    • Contraindicated: Antacids can interfere with the absorption of iron. It’s better to take the iron supplement with vitamin C or a source of vitamin C to enhance absorption.
  3. “Drinking orange juice with this medication decreases the absorption of the medication.”
    • Contraindicated: This statement is incorrect. Vitamin C, found in orange juice, actually enhances the absorption of iron.
  4. “You can take this medication with meals if you experience discomfort when taking it on an empty stomach.”
    • Indicated: Taking iron supplements with food can help reduce gastrointestinal discomfort, although it may slightly reduce absorption.

Teaching Statement

Indicated

Contraindicated

It is expected for your stools to be black while taking this medication.

✓

Take this medication with an antacid if you experience heartburn from the medication.

✓

Drinking orange juice with this medication decreases the absorption of the medication.

✓

You can take this medication with meals if you experience discomfort when taking it on an empty stomach.

Correct Answer is D

Explanation

Choice A rationale
Hyperglycemia is not a common adverse effect of colesevelam. Colesevelam is primarily used to lower cholesterol levels and can also help control blood sugar levels in patients with type 2 diabetes.
Choice B rationale
Stomatitis, or inflammation of the mouth, is not typically associated with colesevelam. This medication works in the intestines and is not absorbed into the bloodstream, so it does not commonly cause systemic side effects.
Choice C rationale
Fever is not a known adverse effect of colesevelam. The medication’s side effects are generally limited to the gastrointestinal system.
Choice D rationale
Constipation is a common adverse effect of colesevelam. This medication binds to bile acids in the intestines, which can lead to gastrointestinal side effects such as constipation.

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