A nurse is caring for a client who has a prescription for a peripheral IV catheter.

After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?

Hyperthermia is a condition in which the body temperature is abnormally high, usually due to exposure to heat, infection, or certain medications.

Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.

Choice A is wrong because covering the adolescent with a thermal blanket would increase the body temperature and worsen hyperthermia. The nurse should remove excess clothing and use cooling measures, such as fans, ice packs, or cool fluids.

Choice B is wrong because submerging the adolescent’s feet in ice water would cause vasoconstriction and shivering, which would reduce heat loss and increase heat production. The nurse should avoid using extreme cold or ice water to cool the body.

Choice D is wrong because administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications.

Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.

Normal body temperature ranges from 36.5°C to 37.5°C (97.7°F to 99.5°F). Hyperthermia is defined as a body temperature above 38.5°C (101.3°F).

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

• Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
• Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.

Choice A rationale:

• Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
• Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

• Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
• Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

• Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
• Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.