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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 D

Explanation

A. Altered nutrition is a concern but is not the immediate priority.
B. Activity intolerance is expected but does not pose an immediate threat.
C. Fluid volume excess should be monitored, but ineffective airway clearance poses a more immediate risk.
D. Ineffective airway clearance is the highest priority because a flank incision can cause significant pain, leading to shallow breathing and increased risk for atelectasis or pneumonia.

A. Evaluate the UAP for signs of improvement. B. Plan for scheduled break times. C. Note date and time of the behavior. D. Discuss the issue privately with the UAP.

Correct Answer is C,D,B,A

Explanation

First, the manager should document the behavior to create an official record of what occurred. Next, it is important to address the issue directly with the UAP in a private discussion, giving the individual an opportunity to explain their actions. Following the discussion, planning for scheduled breaks is a proactive measure to ensure that the UAP has structured downtime, reducing the likelihood of similar behavior. Finally, evaluating the UAP for signs of improvement will help determine whether the intervention strategies have been effective and whether further action is necessary.

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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

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

Correct Answer is D

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is C,D,B,A

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.