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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Participation of community leaders in planning the program is crucial because these leaders have an in-depth understanding of the community's needs and concerns. Their involvement ensures that the program is culturally relevant and addresses the specific health disparities faced by African-American women. Additionally, community leaders can help foster trust and encourage participation from community members, making the program more effective.
Choice B rationale
While morbidity data for breast cancer in women of all races can provide valuable information on overall trends, it does not address the specific needs and challenges faced by African-American women. Focusing on the unique risks and barriers faced by this group is essential for designing an effective health promotion program.
Choice C rationale
A listing of African-American women who live in the community is useful for outreach and engagement but does not provide the essential insight needed to design a culturally sensitive and relevant program. Participation from community leaders is more effective in understanding and addressing the community's specific needs.
Choice D rationale
Technical assistance to produce a video on breast self-examination is valuable for education but is not the most important resource for designing a comprehensive health promotion program. The program must be tailored to the community's unique needs, which requires input from community leaders.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Calcium carbonate is a common medication used to manage low calcium levels, but in clients with hyperparathyroidism, it can exacerbate hypercalcemia, leading to dangerous levels of calcium in the blood. Hyperparathyroidism already causes increased calcium release from bones, increased absorption from the intestines, and decreased excretion by the kidneys, so adding calcium carbonate can worsen these effects, potentially leading to complications like kidney stones, bone pain, and cardiovascular issues. Careful monitoring and possible dose adjustments or discontinuation might be necessary.
Choice B rationale
Acetaminophen is an analgesic and antipyretic commonly used for pain relief and fever reduction. It is metabolized primarily in the liver and does not significantly impact calcium levels or parathyroid hormone function. Therefore, it does not pose an immediate concern for clients with hyperparathyroidism and can typically be used safely without requiring further discussion with the healthcare provider unless there are other contraindications or hepatic issues in the client's medical history.
Choice C rationale
Hydrochlorothiazide is a thiazide diuretic often used to manage hypertension and edema. It reduces urine calcium excretion, which can lead to increased serum calcium levels, exacerbating hypercalcemia in clients with hyperparathyroidism. Thiazide diuretics promote calcium reabsorption in the distal convoluted tubules of the kidneys, potentially worsening the hypercalcemia caused by hyperparathyroidism. Therefore, the use of hydrochlorothiazide should be carefully evaluated and potentially avoided in these clients.
Choice D rationale
Lithium carbonate is used to treat bipolar disorder and can affect parathyroid function, leading to increased parathyroid hormone (PTH) levels and hypercalcemia. Lithium can alter the set point of the calcium-PTH feedback loop, leading to increased release of PTH, even at normal calcium levels. This can result in worsening hyperparathyroidism and hypercalcemia, making it a medication that requires careful consideration and monitoring in affected clients.
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