A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next?
Hold opioid analgesics until the patient is warmer.
Notify the anesthesia care provider.
Cover the patient with a warm blanket.
Give acetaminophen 650 mg suppository rectally.
The Correct Answer is C
C. Covering the patient with a warm blanket is an appropriate initial intervention to address the patient's hypothermia and shivering. Heat conservation measures, such as using blankets or warming devices, help raise the patient's body temperature and alleviate shivering.
A. While shivering and a low body temperature (hypothermia) can be common postoperative complications, holding opioid analgesics may not directly address the underlying cause of the shivering or hypothermia.
B. Notifying the anesthesia care provider is a prudent action, especially if the patient's shivering and hypothermia are suspected to be related to intraoperative factors such as inadequate warming or anesthesia-induced temperature dysregulation. However, this is not the immediate action.
D. Acetaminophen is not typically indicated as the initial treatment for hypothermia or shivering. While acetaminophen can help reduce fever and discomfort, rectal suppositories may not provide rapid temperature elevation or relief from shivering.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Acute compartment syndrome occurs when increased pressure within a muscle compartment compromises circulation to the muscles and nerves within that compartment. Fractures, especially those accompanied by significant soft tissue injury or bleeding, can lead to compartment syndrome.
A Osteomyelitis is an infection of the bone that can occur as a complication of fractures, particularly if the fracture is open (the bone breaks through the skin). This occurs in the later courses of an infection.
C Fat embolism syndrome occurs when fat globules from fractured bones enter the bloodstream and become lodged in small blood vessels in organs such as the lungs, brain, and skin. Increasing edema is not an early sign of fat embolism.
D Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs and blocks blood flow. While fractures, especially long bone fractures, can increase the risk of developing blood clots, increasing edema in the fractured limb is not typically an early sign of pulmonary embolism.
Correct Answer is C
Explanation
C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.
A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.
B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.
D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.
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