A nurse is collecting data for a client who is postoperative and has an elevated temperature. Which of the following actions should the nurse take first?

Assist the client with dangling off the side of the bed.

Check the condition of the client's surgical incision.

Instruct the client to breathe deeply and cough.

Obtain a prescription to check the client's CBC.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Assist the client with dangling off the side of the bed: Early ambulation is important in the postoperative period to prevent complications such as atelectasis or deep vein thrombosis. However, it is not the first action when an elevated temperature is observed, as the cause of the fever must be assessed first.

B. Check the condition of the client's surgical incision: Inspecting the surgical site addresses a potential source of infection, which is a common cause of postoperative fever. This direct assessment helps determine whether local inflammation, drainage, or other signs of infection are present and guides further intervention.

C. Instruct the client to breathe deeply and cough: Encouraging deep breathing and coughing promotes lung expansion and reduces the risk of atelectasis and pneumonia, other causes of postoperative fever. While beneficial, checking the incision for infection is a more direct and immediate assessment for a common and serious cause of postoperative fever.

D. Obtain a prescription to check the client's CBC: A CBC can provide useful information on infection or inflammation, but obtaining lab orders should come after performing a focused assessment to gather immediate, observable data that may warrant urgent action.

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Correct Answer is C

Explanation

Rationale:

A. Librium: Librium (chlordiazepoxide) is a benzodiazepine used primarily during alcohol withdrawal to manage symptoms such as anxiety, tremors, or seizures. It is not used for long-term relapse prevention due to the risk of dependence and lack of deterrent effect on alcohol use.

B. Clonidine: Clonidine is an antihypertensive agent that can help reduce autonomic symptoms during acute alcohol or opioid withdrawal. However, it does not play a role in preventing relapse or deterring future alcohol use.

C. Disulfiram: Disulfiram works by producing unpleasant effects like nausea and vomiting when alcohol is consumed, thereby discouraging the client from drinking. It is specifically used for relapse prevention in clients who are motivated to remain abstinent and understand the consequences of drinking while on the medication.

D. Phenobarbital: Phenobarbital, a barbiturate, may be used in certain alcohol withdrawal protocols for seizure control or severe withdrawal symptoms. However, it is not used for relapse prevention and carries a high potential for dependence and sedation.

A. Provide the caregiver with information on behavior therapy. B. Screen the child for depression prior to initiating the medication. C. Monitor liver function test results while the child is taking the medication D. Monitor the child for nightmares while taking the medication. E. Monitor the child's blood pressure at each visit.

Correct Answer is ["A","C","D","E"]

Explanation

A.Provide the caregiver with information on behavior therapy: Behavior therapy is a first-line, evidence-based nonpharmacologic intervention for ADHD, particularly in children. Educating caregivers about behavioral strategies helps improve symptom management and supports long-term success.
B. Screen the child for depression prior to initiating the medication: Although screening for comorbid conditions like depression is important in ADHD management, it is typically part of the initial diagnostic workup, which was already completed with neurology and developmental evaluations.
C. Monitor liver function test results while the child is taking the medication: Atomoxetine carries a risk of rare but serious liver toxicity. Regular monitoring of liver function is essential during treatment, especially if the child shows signs of liver dysfunction (e.g., dark urine, abdominal pain, jaundice).
D. Monitor the child for nightmares while taking the medication: Sleep disturbances, including insomnia and nightmares, are known side effects of atomoxetine. Nurses should monitor and educate caregivers about possible changes in sleep behavior while the child is on this medication.
E.Monitor the child's blood pressure at each visit: Atomoxetine can cause increases in blood pressure and heart rate. Routine monitoring of vital signs at follow-up visits is necessary to ensure cardiovascular safety during treatment.

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A nurse is collecting data for a client who is postoperative and has an elevated temperature. Which of the following actions should the nurse take first?

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