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The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Apply warm blankets

Use a fluid warmer for intravenous fluids

Place ice packs around the client's head

Administer an antipyretic

Administer intravenous fluids with a rapid infuser

Microwave a pack of gauze and distribute across the body

Answer and Explanation

Correct Answer : A,B,C,D,G

A. Check the temperature of the humidified oxygen attached to the ventilator: Ventilator circuits often include humidified air, and ensuring it is warm helps prevent further heat loss. Cold oxygen delivery can contribute to hypothermia in intubated clients.

B. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help raise core body temperature and are an appropriate method for internal rewarming in a hypothermic trauma patient.

C. Apply warm blankets: This is a safe, effective, and commonly used external warming method to treat mild hypothermia. Warm blankets help prevent further heat loss and support gradual rewarming.

D. Use a fluid warmer for intravenous fluids: Infusing cold fluids can worsen hypothermia. Using a fluid warmer helps maintain core temperature and is especially important during rapid fluid administration.

E. Place ice packs around the client's head: This intervention would lower body temperature and is contraindicated in hypothermia. It is used to reduce fever or manage increased intracranial pressure, not to treat low temperatures.

F. Administer an antipyretic: Antipyretics are used to reduce fever, not to raise body temperature. In a hypothermic client, they are inappropriate and potentially harmful.

G. Administer intravenous fluids with a rapid infuser: A rapid infuser should only be used with warmed fluids. When used with a fluid warmer, it helps maintain core temperature during large-volume resuscitation.

H. Microwave a pack of gauze and distribute across the body: This is unsafe and not evidence-based. Microwaving gauze creates a burn hazard and provides no controlled or measurable warming benefit.

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Correct Answer is D

Explanation

A. Catheter tubing: While catheter tubing can become contaminated and contribute to infection, it is not the primary reservoir in this scenario where the catheter bag resting on the bed surface likely introduced external pathogens.

B. Client's bladder: The bladder is typically sterile unless an infection has already occurred; in this case, the infection is secondary to contamination from an external source, not an internal origin.

C. Urinary meatus: The urinary meatus can harbor some normal flora, but it is not considered the source or reservoir of the infection linked to the catheter bag being placed on the bed.

D. The client's bed: The bed, an external environment, can harbor bacteria that contaminate the catheter bag and ascend into the urinary tract, making it the reservoir for the infection in this situation.

A. Administering bolus fluids B. Side positioning C. Urinary drainage D. Assisting with pushing efforts E. Administering IV fluids F. Monitoring blood pressure

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A,B"}}

Explanation

Intervention	Fetus	Maternal
Administering bolus fluids	✔	✔
Side positioning	✔	✔
Urinary drainage		✔
Assisting with pushing efforts		✔
Administering IV fluids		✔
Monitoring blood pressure	✔	✔

• Administering bolus fluids: Increases maternal intravascular volume to reduce the risk of epidural-induced hypotension. Stable maternal blood pressure helps maintain adequate uteroplacental perfusion. This ensures continuous oxygen delivery to the fetus during labor.

• Side positioning: Prevents compression of the inferior vena cava by the gravid uterus. This improves venous return and cardiac output, enhancing blood flow to the placenta. Helps avoid supine hypotension syndrome, maintaining maternal blood pressure and fetal perfusion. Fetal oxygenation is better preserved in side-lying positions.

• Urinary drainage: Prevents bladder overdistention caused by sensory and motor blockade from epidural anesthesia. A full bladder can hinder fetal descent and prolong labor. Catheterization protects maternal comfort and labor progression.

• Assisting with pushing efforts: Supports the second stage of labor when the epidural limits maternal bearing-down ability. Coaching synchronizes maternal effort with contractions. This intervention improves efficiency of pushing and fetal descent.

• Administering IV fluids: Maintains adequate preload to prevent vasodilation-related hypotension after epidural administration. Consistent fluid support sustains maternal blood pressure and perfusion to uterine arteries during labor.

• Monitoring blood pressure: Detects early signs of hypotension, a common adverse effect of epidural anesthesia. Frequent readings guide prompt intervention to stabilize maternal hemodynamics. This protects both maternal safety and fetal well-being.

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The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Correct Answer is D

Explanation

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one response selected.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A,B"}}

Explanation

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