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Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Place ice packs around the client's head

Microwave a pack of gauze and distribute across the body

Administer intravenous fluids with a rapid infuser

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Use a fluid warmer for intravenous fluids

Apply warm blankets

Administer an antipyretic

Answer and Explanation

Correct Answer : C,D,E,F,G

A. Place ice packs around the client's head: This is a cooling intervention used for hyperthermia, not for treating hypothermia.
B. Microwave a pack of gauze and distribute across the body: This is unsafe, as microwaved materials can cause burns and do not provide effective heat distribution.
C. Administer intravenous fluids with a rapid infuser: Rapid infusion of warmed IV fluids can help restore core body temperature and prevent further hypothermia.
D. Check the temperature of the humidified oxygen attached to the ventilator: Cold or dry oxygen can contribute to heat loss, so ensuring that the humidified oxygen is warmed is an important step in maintaining normothermia.
E. Instill warm fluids in the nasogastric tube: Lavage with warm fluids via NG tube is an effective method of internal warming for hypothermic patients.
F. Use a fluid warmer for intravenous fluids: Warming IV fluids before administration prevents additional heat loss that could occur if room-temperature fluids are given.
G. Apply warm blankets: Passive external warming using warm blankets is an easy and effective intervention to increase body temperature.
H. Administer an antipyretic: Antipyretics (e.g., acetaminophen, ibuprofen) are used for fevers, not for hypothermia.

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Correct Answer is C

Explanation

A. Advancing to clear liquids is important for nutritional support but is secondary to ensuring urinary function is restored.

B. Urinary retention is a concern after anesthesia, but it is not an immediate threat. This intervention is conditional (“if unable to void”), meaning it is implemented only if needed.

C. Postoperative clients are at high risk for infection. Cefazolin (a broad-spectrum antibiotic) is a prophylactic measure to reduce the risk of surgical site infection, which is a priority intervention immediately after surgery. This should be implemented first, since infection prevention begins as soon as the client arrives from PACU.

D. A CBC is important for monitoring but is not urgent in comparison to immediate care needs like urinary output.

A. PO administration of divalproex. B. IV administration of isotonic crystalloid fluid. C. PO administration of lorazepam. D. IV administration of benztropine.

Correct Answer is D

Explanation

A. Divalproex is an anticonvulsant and is not indicated for the treatment of acute dystonic reactions.
B. IV isotonic crystalloid fluid is used for hydration but is not the primary treatment for dystonic reactions.
C. Lorazepam is a benzodiazepine, which may be used for anxiety or seizure activity, but is not effective for managing dystonic reactions.
D. Benztropine is an anticholinergic medication used to treat acute dystonic reactions, including those causing laryngeal spasms. It works by reducing the excessive cholinergic activity that leads to these symptoms.

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Exhibits The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Correct Answer is C

Explanation

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is D

Explanation

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Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.