A nurse is monitoring a patient who had general anesthesia for a hernia repair. Which of the following findings indicate that the patient is at risk for hypothermia? (Select all that apply.)

Shivering.

Tachycardia.

Pallor.

Diaphoresis.

Hypotension.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason:

Shivering is a sign of hypothermia because it is the body's way of generating heat when the core temperature drops below normal. Shivering can be uncontrollable in mild hypothermia and may stop in moderate to severe hypothermia as the body conserves energy.

Choice B reason:

Tachycardia is not a sign of hypothermia. In fact, hypothermia can cause bradycardia, which is a slow heart rate, as the body tries to reduce heat loss through the blood vessels.

Choice C reason:

Pallor is a sign of hypothermia because it indicates reduced blood flow to the skin as the blood vessels constrict to preserve core temperature. Pallor can also be accompanied by cyanosis, which is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood.

Choice D reason:

Diaphoresis is a sign of hypothermia because it is the result of excessive sweating that can occur after exposure to cold or wet environments. Sweating can increase heat loss through evaporation and lower the body temperature further.

Choice E reason:

Hypotension is a sign of hypothermia because it reflects decreased cardiac output and blood pressure as the heart muscle becomes less efficient and responsive to stimuli. Hypotension can also lead to shock, organ failure, and death if not treated promptly.

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Correct Answer is ["E"]

Explanation

Choice A reason:

This statement is correct and does not indicate a need for further teaching. The client can resume normal activities in a week after a laparoscopic cholecystectomy.

Choice B reason:

This statement is correct and does not indicate a need for further teaching. The client can take acetaminophen for pain relief after a laparoscopic cholecystectomy.

Choice C reason:

This statement is correct and does not indicate a need for further teaching. The client can shower the day after surgery and pat the incisions dry to prevent infection.

Choice D reason:

This statement is correct and does not indicate a need for further teaching. The client can eat a low-fat diet for the first month to avoid stimulating the gallbladder and causing pain.

Choice E reason:

This statement is incorrect and indicates a need for further teaching. The client should not expect any drainage from the incisions, as this could indicate infection or leakage of bile. The client should report any drainage to the provider immediately. A) “I can resume my normal activities in a week.” B) “I can take acetaminophen for pain relief.” C) “I can shower tomorrow and pat my incisions dry.” D) “I can eat a low-fat diet for the first month.” E) “I can expect some drainage from my incisions.”

A. "I understand how you feel, but staying in bed can cause complications.” B. "You need to get out of bed at least three times a day to prevent blood clots.” C. "Let me give you some pain medication and then we can try getting up.” D. "Getting out of bed will help you heal faster and reduce your pain.” E. "Why don't you want to get out of bed? Are you afraid of something?".

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

Explanation

Choice A reason:

This response is not appropriate because it does not acknowledge the patient's pain or offer any pain relief. It also sounds dismissive and unsympathetic to the patient's feelings. A better response would be to empathize with the patient and explain the benefits and risks of early mobilization in a respectful way.

Choice B reason:

This response is not appropriate because it does not address the patient's pain or provide any pain relief. It also sounds demanding and authoritarian, which may increase the patient's anxiety and resistance. A better response would be to collaborate with the patient and set realistic and individualized goals for mobility.

Choice C reason:

This response is appropriate because it acknowledges the patient's pain and offers a solution to reduce it. It also shows respect for the patient's autonomy and readiness by suggesting rather than ordering to get up. It also implies that the nurse will assist and support the patient during the activity.

Choice D reason:

This response is appropriate because it provides positive reinforcement and education to the patient. It explains how early mobilization can enhance wound healing and decrease pain by improving blood circulation, preventing complications, and restoring function.

Choice E reason:

This response is not appropriate because it sounds accusatory and judgmental. It may make the patient feel defensive or guilty for expressing their pain or reluctance. A better response would be to explore the patient's concerns and fears in a non-threatening way and provide reassurance and information as needed.

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A nurse is monitoring a patient who had general anesthesia for a hernia repair. Which of the following findings indicate that the patient is at risk for hypothermia? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing discharge instructions with a client who had a laparoscopic cholecystectomy. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

Correct Answer is ["E"]

Explanation

A client who had surgery yesterday tells the nurse, "I don't want to get out of bed because it hurts too much.” Which responses by the nurse are appropriate? (Select all that apply.)

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

Explanation

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