A nurse is caring for a client who has a rectal temperature of 35°C (95°F). Which of the following actions should the nurse take?

Decrease the temperature in the client's room.

Request a prescription for an antipyretic medication.

Place a cooling fan near the client.

Place a warming blanket over the client.

Answer and Explanation

The Correct Answer is D

A reason:

Decreasing the temperature in the client's room is incorrect. The client is already hypothermic and needs to be warmed, not further cooled.

B reason:

Requesting a prescription for an antipyretic medication is inappropriate. Antipyretics are used to lower fever, not to treat hypothermia.

C reason:

Placing a cooling fan near the client is incorrect and would exacerbate hypothermia.

D reason:

Placing a warming blanket over the client is correct. This action helps to gradually raise the client's body temperature to a safe level.

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Correct Answer is A

Explanation

A reason: Yellow-green drainage on the surgical incision. Yellow-green drainage indicates a potential infection at the surgical site. Postoperative infections can complicate the healing process and require prompt medical intervention. This finding should be reported to the provider immediately.

B reason: Straw-colored urine from an indwelling urinary catheter. Straw-colored urine is a normal finding and does not indicate any complications related to the surgery. This choice does not require reporting to the provider as it is within the normal range of expected outcomes.

C reason: Blood pressure 112/76 mm Hg. This blood pressure reading is within the normal range and does not indicate any immediate postoperative complications. There is no need to report this finding as it does not suggest an adverse event.

D reason: Respiratory rate 18/min. A respiratory rate of 18 breaths per minute is within the normal range for adults and does not indicate any respiratory distress or other complications. This finding does not require reporting to the provider.

A. Blood pressure. B. Cyanosis. C. Nausea. D. Petechiae.

Correct Answer is C

Explanation

A reason: Blood pressure. Blood pressure is an objective measurement that can be quantitatively assessed using a sphygmomanometer. It is not considered subjective data because it does not rely on the client's perception or feelings.

B reason: Cyanosis. Cyanosis, or the bluish discoloration of the skin, is an observable physical sign that can be assessed by the healthcare provider. It is considered objective data, not subjective.

C reason: Nausea. Nausea is a subjective symptom reported by the client. It is based on the client's personal experience and cannot be directly observed or measured by the healthcare provider, making it subjective data.

D reason: Petechiae. Petechiae are small, red or purple spots on the skin caused by minor bleeding. These are observable and measurable physical signs, thus considered objective data.

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A nurse is caring for a client who has a rectal temperature of 35°C (95°F). Which of the following actions should the nurse take?

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