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.

Answer and Explanation

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.

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Correct Answer is ["25"]

Explanation

The nurse should regulate the IV flow at 25 gtts/min.

Calculation and Answer

Step 1: Determine the total volume to be infused.

Volume = 100 mL

Step 2: Determine the time over which the infusion will occur.

Time = 1 hour = 60 minutes

Step 3: Determine the drip factor.

Drip factor = 15 gtts/mL

Step 4: Calculate the IV flow rate using the formula:

Flow rate (gtts/min) = (Volume (mL) × Drop factor (gtts/mL)) ÷ Time (min)

Step 5: Substitute the values into the formula.

Flow rate (gtts/min) = (100 mL × 15 gtts/mL) ÷ 60 min

Step 6: Perform the multiplication.

100 mL × 15 gtts/mL = 1500 gtts

Step 7: Perform the division.

1500 gtts ÷ 60 min = 25 gtts/min

The nurse should regulate the IV flow at 25 gtts/min.

A. Increase in cellular size of the bronchi and bronchioles. B. Overexpansion of the diaphragm. C. A decreased ability to inhale. D. Destruction of alveolar walls and loss of lung elasticity.

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.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives an order to administer drug R 300 mg IVPB over one hour. Drug R is available as 300 mg in 100 mL NSS. The drip factor of the piggyback tubing is 15 gtts/mL. At what rate should the nurse regulate the IV flow?

Correct Answer is ["25"]

Explanation

The nurse recognizes that the primary physiologic problem affecting clients with emphysema is:

Correct Answer is D

Explanation

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