The nurse is caring for a client who has a core temperature of 97°F (36.1°C) post-op in the post-anesthesia care unit. What action(s) will the nurse take in light of this finding? (Select all that apply)
Give a unit of packed red blood cells as ordered.
Provide warm irrigation to the operative site.
Provide warmed IV fluids.
Provide a warm blanket.
Give acetaminophen per rectum per order because the client is NPO.
Correct Answer : C,D
Choice A reason:
Giving a unit of packed red blood cells is not typically indicated solely for a core temperature of 97°F (36.1°C). This intervention is usually reserved for cases of significant blood loss or anemia. Hypothermia in the postoperative period is more effectively managed with warming techniques rather than blood transfusions.
Choice B reason:
Providing warm irrigation to the operative site is not a standard intervention for managing mild hypothermia postoperatively. While warm irrigation can be used intraoperatively to maintain body temperature, it is not typically used postoperatively.
Choice C reason:
Providing warmed IV fluids is an appropriate intervention for a client with a core temperature of 97°F (36.1°C). Warmed IV fluids help to increase the core body temperature and prevent further heat loss. This is a standard practice in managing mild hypothermia in postoperative patients.
Choice D reason:
Providing a warm blanket is another effective intervention for managing mild hypothermia. Warm blankets help to increase the patient’s body temperature by reducing heat loss and providing external warmth. This is a common and effective method used in postoperative care.
Choice E reason:
Giving acetaminophen per rectum is not indicated for managing hypothermia. Acetaminophen is used to reduce fever, not to increase body temperature. In this scenario, the client needs warming interventions rather than antipyretic medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
An increase in cellular size of the bronchi and bronchioles is not the primary issue in emphysema. Emphysema primarily affects the alveoli, the tiny air sacs in the lungs, rather than the bronchi and bronchioles.
Choice B reason:
Overexpansion of the diaphragm is not a primary problem in emphysema. While the diaphragm may become flattened due to hyperinflation of the lungs, this is a secondary effect rather than the primary issue.
Choice C reason:
A decreased ability to inhale is not the main problem in emphysema. The primary issue is difficulty exhaling due to the loss of elasticity in the alveolar walls, which leads to air trapping and hyperinflation
Choice D reason:
Destruction of alveolar walls and loss of lung elasticity is the primary physiologic problem in emphysema. This destruction leads to reduced surface area for gas exchange and impaired lung function. The loss of elasticity makes it difficult for the lungs to expel air, leading to air trapping and hyperinflation.
Correct Answer is A
Explanation
The tuberculin skin test (TST), also known as the Mantoux test, is used to determine if a person has been infected with the tuberculosis (TB) bacteria. The test involves injecting a small amount of purified protein derivative (PPD) into the skin of the forearm. The injection site is then examined 48 to 72 hours later for a reaction, which is measured in millimeters of induration (swelling).
Choice A reason:
Sunday morning is the correct time to read the test results. Since the test was administered on Thursday at 1200, the 48 to 72-hour window for reading the results would fall between Saturday at 1200 and Monday at 1200. Reading the results on Sunday morning falls within this time frame, making it the appropriate choice.
Choice B reason:
Saturday morning is not the correct time to read the test results. Reading the test results on Saturday morning would be less than 48 hours after the test was administered, which is too early to accurately assess the reaction. The test needs to be read between 48 and 72 hours after administration to ensure accurate results.
Choice C reason:
Friday morning is also not the correct time to read the test results. Reading the test results on Friday morning would be only 24 hours after the test was administered, which is far too early. The immune response to the PPD injection takes time to develop, and reading the test too early can result in a false-negative result.
Choice D reason:
Monday morning is within the acceptable time frame to read the test results, but it is at the very end of the 72-hour window. While it is still technically correct, it is generally recommended to read the test closer to the 48-hour mark to ensure the most accurate results. Therefore, Sunday morning is a better choice.
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