Page the admitting anesthesiologist STAT.

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.

Recheck all vital signs including core temperature.

Apply oxygen via nasal prongs at 4 L/minute.

Continue to monitor vital signs every hour.

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

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Rechecking all vital signs, including core temperature, is essential to assess the client's overall status and identify any changes that may indicate a worsening condition or complications such as infection.

Choice B rationale

Applying oxygen via nasal prongs at 4 L/minute helps ensure adequate oxygenation, which is crucial for patients who may be experiencing postoperative complications, including fever and increased metabolic demand.

Choice C rationale

Continuing to monitor vital signs every hour is important to detect any further changes in the patient's condition and provide timely interventions if needed. Frequent monitoring allows for close observation of trends.

Choice D rationale

Exposing the client's extremities and applying ice packs to the axilla can help reduce fever by promoting heat loss. This intervention is beneficial in managing elevated body temperature and preventing complications associated with hyperthermia.

Nursing Test Bank

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Free Nursing Study Resources

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

Explanation

Choice A rationale

Noting the date and time of the behavior is the first step in addressing the issue, providing a record for future reference and ensuring accuracy in documentation.

Choice C rationale

Planning for scheduled break times helps address potential reasons for the behavior, offering a structured solution to prevent recurrence and improve overall workflow.

Choice B rationale

Evaluating the UAP for signs of improvement is the final step, assessing whether the implemented interventions have been effective and if further actions are needed.

A. Recheck all vital signs including core temperature. B. Apply oxygen via nasal prongs at 4 L/minute. C. Continue to monitor vital signs every hour. D. Expose client's extremities and apply ice packs to axilla.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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Naxlex Comprehensive Predictor Exams

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 ["A","B","C"]

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

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