The nurse is caring for a client who has had an upper G.I. endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed assistant to take the vital signs. Two hours later, the assistant reports to client who was previously afebrile has now developed a temperature of 101.8°F. What should the nurse do in response to this reported data by the unlicensed assistant?
Promptly assess the client for a potential perforation
Tell the assistant to change thermometers and retake the temperature
Plan to give the client acetaminophen the lower temperature
Ask the assistant to bathe the client with tap water
The Correct Answer is A
A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Chronic alcohol consumption can contribute to ulcers but is not the primary cause of duodenal ulcers. It can increase stomach acid and irritate the mucosal lining.
B. High intake of spicy foods is often blamed for ulcers, but it is not a direct cause. Spicy foods may exacerbate symptoms but do not cause ulcers.
C. Inadequate fiber intake is not a significant factor in the development of duodenal ulcers. Diet can influence overall digestive health but is not the main cause.
D. Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin and ibuprofen, are a leading cause of duodenal ulcers. They inhibit prostaglandin production, which protects the mucosal lining of the stomach and duodenum, leading to ulcer formation and increased risk of bleeding.
Correct Answer is B
Explanation
A. Cytotec does not enhance the pain-relieving effects of NSAIDs. Instead, it works to protect the stomach lining from the harmful effects of NSAIDs, which can cause gastrointestinal ulcers and bleeding.
B. Misoprostol (Cytotec) is used to protect the stomach lining from damage caused by NSAIDs, which can increase the production of stomach acid and decrease the protective mucus lining. Cytotec helps prevent gastric ulcers and other GI complications associated with long-term NSAID use.
C. Cytotec does not directly decrease inflammation in the joints. NSAIDs are the primary medications for reducing joint inflammation in conditions like arthritis.
D. Cytotec does not reduce the risk of developing blood clots from NSAIDs. It is primarily used for its protective effect on the gastrointestinal system.
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