Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

Expose client's extremities and apply ice packs to axilla.

Recheck all vital signs including core temperature.

Continue to monitor vital signs every hour.

Apply oxygen via nasal prongs at 4 L/minute.

Page the admitting anesthesiologist STAT

Answer and Explanation

Correct Answer : B,D,E

A. Ice packs can be used but are not the first priority.
B. Rechecking core temperature confirms the severity of hyperthermia.
C. Monitoring hourly is insufficient for a rapidly rising temperature.
D. Oxygen helps prevent hypoxia from hypermetabolic states.
E. Malignant hyperthermia is a medical emergency requiring immediate intervention.

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Correct Answer is C

Explanation

A. Intubation is not the first step unless the client's respiratory status continues to deteriorate despite oxygen therapy.

B. Obtaining a sputum culture may be helpful but does not address the immediate respiratory compromise.

C. A nonrebreather mask with 100% oxygen provides high-flow oxygen and is essential for a client with worsening dyspnea and low oxygen saturation.

D. A forward-leaning position may help with breathing but does not provide the necessary oxygen support in this acute situation.

A. Alert and oriented B. chest pain described as pressure and tightness that is unrelieved with rest C. Radial and pedal pulses 2+ D. Capillary refill 2 seconds E. Rapid and shallow breaths F. Clear breath sounds throughout bilateral lungs G. 7 on a 0 to 10 scale, tightness and pressure in chest

Correct Answer is ["B","E","G"]

Explanation

Chest pain described as pressure and tightness that is unrelieved with rest: Chest pain that is described as tightness and pressure, particularly when unrelieved by rest, is a classic presentation of acute coronary syndrome (ACS), which includes conditions such as unstable angina or myocardial infarction (MI). This is a red flag symptom, as it indicates a need for immediate medical attention to rule out life-threatening conditions like MI, which can be fatal without timely intervention.

Rapid shallow breaths: Rapid and shallow breathing can be a response to acute pain, particularly in a situation involving cardiovascular stress. It may be indicative of the body's attempt to compensate for inadequate oxygenation due to cardiac ischemia, hypoxia, or anxiety.

Pain 7/10, tightness and pressure in the chest: A pain rating of 7/10 demands immediate evaluation and management, as it could indicate an evolving cardiovascular event. Moreover, tightness and pressure are specific descriptors of pain seen in ischemic heart disease, where there is reduced blood flow to the heart muscle, leading to discomfort due to oxygen deprivation.

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Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["B","E","G"]

Explanation

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