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 ["B","C","E"]

Explanation

A. Keeping the room brightly lit may contribute to confusion or agitation, especially in an acute stroke client.

B. Monitoring speech for changes is critical in stroke patients, as sudden changes can indicate worsening neurological status.

C. Changes in level of consciousness can indicate deterioration, and should be promptly reported to the nurse.

D. Minimizing verbal interaction may not be helpful as it could isolate the client. It's more important to provide clear and calm communication.

E. Avoiding sudden movements or sounds, such as dropping side rails or abruptly closing doors, can help reduce agitation and prevent injury.

A. Place ice packs around the client's head B. Microwave a pack of gauze and distribute across the body C. Administer intravenous fluids with a rapid infuser D. Check the temperature of the humidified oxygen attached to the ventilator E. Instill warm fluids in the nasogastric tube F. Use a fluid warmer for intravenous fluids G. Apply warm blankets H. Administer an antipyretic

Correct Answer is ["C","D","E","F","G"]

Explanation

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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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

A client is admitted during the acute phase of a stroke. The nurse observes that the client is restless and unable to follow instructions. Which instruction(s) should the nurse provide the unlicensed assistive personnel (UAP) who is assisting with the care of the client? Select all that apply.

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

Explanation

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.

Correct Answer is ["C","D","E","F","G"]

Explanation

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