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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Metal objects, including jewelry, can interfere with the DXA scan and affect the quality of the images. Therefore, it is important for the client to remove all jewelry and metal objects before the test to ensure accurate results.

B. Fasting is not typically required for a dual-energy x-ray absorptiometry (DXA) scan. DXA scans are non- invasive and do not involve the administration of any substances that would necessitate fasting.

C. This instruction is not specifically required for a DXA scan. However, it is generally a good practice for clients to empty their bladder before any imaging test to ensure comfort during the procedure.

D. This instruction is not accurate for a DXA scan. DXA scans are typically quick procedures that do not require the client to lie flat for an extended period afterward. Clients can resume their normal activities immediately following the scan without any restrictions.

A. Palpate the femoral pulse. B. Monitor the client's calf for edema. C. Instruct the client to wiggle his toes. D. Measure the circumference of the thigh.

Correct Answer is C

Explanation

C. Asking the client to wiggle their toes assesses motor function and nerve integrity. In a neurovascular assessment, intact nerve function is crucial, as impaired nerve function can manifest as weakness or paralysis.

A. This technique assesses the circulation in the lower extremity by checking for the presence, strength, and symmetry of the pulse. However, it assesses for vascular component proximal to the fracture.

B. Edema in the calf muscle is mostly used as a marker for deep venous thrombosis. Although it can affect circulation. It may be a late sign.

D. Significant differences in thigh circumference between the affected and unaffected limb may indicate vascular compromise or other issues. This is however, a late sign of vascular compromise.

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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?

Nursing Test Bank

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