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 D

Explanation

Choice A reason:

Administering oxygen per the prescriber’s order to keep SpO2 greater than 96% is not typically recommended for clients with chronic bronchitis. High levels of oxygen can suppress the respiratory drive in clients with chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis. The target SpO2 for these clients is usually between 88% and 92%.

Choice B reason:

Placing the patient in the Sims position is not the most effective position for airway clearance. The Fowler’s or semi-Fowler’s position is generally preferred as it promotes better lung expansion and facilitates easier breathing.

Choice C reason:

Assessing the client’s use of a peak expiratory flow rate meter is important for monitoring the severity of bronchospasm and airflow obstruction. However, it is not a direct intervention for improving gas exchange.

Choice D reason:

Assisting with coughing and deep breathing at least every 2 hours while awake is an effective intervention for clients with chronic bronchitis. This helps to mobilize secretions, improve ventilation, and enhance gas exchange. Regular coughing and deep breathing exercises can prevent atelectasis and reduce the risk of respiratory infections.

A. Notify the surgeon and anesthesiologist. B. Assume that the client is confused because he is elderly. C. Ask the client to point to his good eye. D. Check to see if the client has received any preoperative medications.

Correct Answer is A

Explanation

Choice A reason: Notifying the surgeon and anesthesiologist is the most appropriate action. This ensures that the discrepancy is addressed immediately and the correct eye is operated on. It is crucial to verify and correct any inconsistencies in the surgical plan to prevent errors and ensure patient safety.

Choice B reason: Assuming that the client is confused because he is elderly is inappropriate and dismissive. Age should not be a factor in disregarding a patient’s statement. The nurse should take the client’s concerns seriously and verify the information rather than making assumptions about the client’s mental state.

Choice C reason: Asking the client to point to his good eye can help clarify the situation, but it is not sufficient on its own. While it may provide additional information, the nurse must still notify the surgical team to ensure that the correct procedure is performed. This step should be part of the verification process but not the sole action taken.

Choice D reason: Checking to see if the client has received any preoperative medications is important, but it does not address the immediate concern of the discrepancy in the consent form. The priority is to ensure that the correct eye is identified for surgery, and this requires notifying the surgical team.

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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 has applied a client problem of ineffective gas exchange for a client diagnosed with chronic bronchitis. Which intervention would the nurse include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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