Patient Data
The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.
Apply warm blankets
Administer an antipyretic
Place ice packs around the client's head
Check the temperature of the humidified oxygen attached to the ventilator
Instill warm fluids in the nasogastric tube
Microwave a pack of gauze and distribute across the body
Administer intravenous fluids with a rapid infuser
Use a fluid warmer for intravenous fluids
Correct Answer : A,D,E,G,H
A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.
B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.
C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.
D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.
E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.
F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.
G. Administer intravenous fluids with a rapid infuser: Warm IV fluids given rapidly restore circulating volume in trauma clients and also help increase core body temperature, addressing both shock and hypothermia.
H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","F"]
Explanation
Rationale for Correct Choices:
- The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
- The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
- The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.
Rationale for Incorrect Choices:
- Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
- Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
- A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}
Explanation
Reduced pulse distal to injury: A humeral fracture can damage surrounding vasculature, especially the brachial artery, leading to compromised circulation. This results in weak or absent distal pulses, which requires urgent evaluation for possible neurovascular compromise.
• Decreased range of motion: Both rotator cuff injury and humeral fracture commonly cause impaired shoulder mobility. A rotator cuff tear limits abduction and overhead activities, while a fracture mechanically restricts movement due to pain, swelling, or bone displacement.
• Coolness of skin: A humeral fracture can impair blood flow by compressing or injuring vessels, producing ischemic changes such as cool skin. This finding signals inadequate perfusion, which can progress to serious complications if untreated.
• Pain with movement: Both a rotator cuff tear and humeral fracture are associated with pain on movement. In a tear, the pain stems from tendon injury and inflammation, while in a fracture, bone disruption and soft tissue trauma intensify pain when the joint is moved.
• 1+ strength in left upper extremity: Weakness in the affected arm is more typical of rotator cuff injury, as tendon disruption limits muscular function and reduces lifting ability. This differs from fracture-related pain, where strength may be preserved but restricted by pain.
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