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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A rationale

An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.

Choice B rationale

An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.

Choice C rationale

An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.

Choice D rationale

An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.

A. Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg B. Oxygen saturation of 100% on 40% FiO₂ C. Heart rate of 128 beats/minute, sinus tachycardia D. CT scan findings of liver and spleen lacerations with blood in the peritoneum E. Temperature of 96.9°F (36.1°C)

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

Explanation

Choice A rationale: Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg is concerning because it indicates hypotension and a narrowed pulse pressure, which can be signs of significant internal bleeding or shock. This requires immediate medical attention to stabilize the client's condition.

Choice B rationale: Oxygen saturation of 100% on 40% FiO₂ is not a critical finding that requires immediate reporting. The client is receiving sufficient oxygen, and the saturation level indicates adequate oxygenation.

Choice C rationale: Heart rate of 128 beats/minute, sinus tachycardia is an important finding because tachycardia can indicate a response to pain, anxiety, hypovolemia, or shock. It needs to be reported to assess and address the underlying cause.

Choice D rationale: CT scan findings of liver and spleen lacerations with blood in the peritoneum are critical because they indicate significant internal injuries and active bleeding. This requires immediate surgical intervention and close monitoring.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is D

Explanation

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

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

Explanation

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?