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 A

Explanation

Choice A reason:

Placing a pillow under the dependent axilla is a proper technique for lateral positioning because it helps to prevent brachial plexus injury by reducing the pressure on the neurovascular structures in the axilla. It also helps to maintain the alignment of the shoulder and prevent shoulder drop.

Choice B reason:

Flexing both knees at a 90-degree angle is not a proper technique for lateral positioning because it can cause excessive pressure on the knees and ankles, leading to nerve injury or skin breakdown. It can also impair venous return and increase the risk of deep vein thrombosis (DVT) Only the dependent leg should be flexed at the hip and knee, while the upper leg should be straight and supported by pillows between the legs.

Choice C reason:

Aligning the shoulders directly over each other is not a proper technique for lateral positioning because it can cause compression of the dependent shoulder and compromise the blood supply to the arm. It can also cause shoulder drop and brachial plexus injury. The lower shoulder should be pulled slightly forward and supported by a pad under the chest wall.

Choice D reason:

Elevating the dependent arm on an arm board is not a proper technique for lateral positioning because it can cause excessive abduction of the arm and stretch the brachial plexus. It can also interfere with surgical access to the thorax or kidney. Both arms should be supported on parallel arm boards with abduction less than 90 degrees.

A. Wearing tight-fitting clothing or jewelry on the affected arm. B. Elevating the affected arm above the level of the heart. C. Applying moisturizer or sunscreen to the affected arm. D. Having blood pressure or blood draws on the affected arm. E. Performing range-of-motion exercises on the affected arm.

Correct Answer is D

Explanation

Choice A reason:

Wearing tight-fitting clothing or jewelry on the affected arm is not recommended, but it is not something to avoid completely. Tight-fitting clothing or jewelry can cause swelling (lymphedema) or infection in the arm, but wearing them for short periods of time may be acceptable. The client should be advised to wear loose-fitting clothing and jewelry most of the time and to monitor the arm for any signs of swelling, pain, or redness.

Choice B reason:

Elevating the affected arm above the level of the heart is not something to avoid, but rather something to do frequently. Elevating the arm can help reduce swelling and improve blood flow. The client should be instructed to elevate the arm several times a day for 15 to 30 minutes at a time.

Choice C reason:

Applying moisturizer or sunscreen to the affected arm is not something to avoid, but rather something to do regularly. Moisturizer can help prevent dryness and cracking of the skin, which can increase the risk of infection. Sunscreen can help protect the skin from sun damage, which can also increase the risk of infection and skin cancer. The client should be advised to apply moisturizer daily and sunscreen whenever exposed to the sun.

Choice D reason:

Having blood pressure or blood draws on the affected arm is something to avoid. This is because these procedures can cause injury or infection to the arm, which can lead to lymphedema or other complications. The client should be instructed to inform all health care providers that they had a mastectomy with lymph node dissection and to request that blood pressure or blood draws be done on the other arm or on another part of the body.

Choice E reason:

Performing range-of-motion exercises on the affected arm is not something to avoid, but rather something to do gradually and carefully. Range-of-motion exercises can help restore mobility and flexibility to the arm and prevent stiffness and contractures. The client should be instructed to start doing gentle exercises as soon as possible after surgery and to increase the intensity and duration as tolerated. The client may be referred to a physical therapist for additional guidance and support.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

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