When a client is using a cooling blanket to reduce fever, which finding indicates the need to change treatment?
Diarrhea
Shivering
Hypotension
Vomiting
The Correct Answer is B
A. Diarrhea: Diarrhea is not a common side effect of cooling therapy and does not indicate a need to stop treatment.
B. Shivering: Shivering counteracts the cooling effect of the blanket, increasing body temperature and metabolic demand. This indicates the treatment is ineffective and needs adjustment.
C. Hypotension: While cooling can cause vasodilation and lower blood pressure, mild hypotension does not immediately necessitate stopping treatment.
D. Vomiting: Vomiting may be due to fever-related illness but is not a direct indicator that cooling should be stopped.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Serum potassium 4.8 mmol/L: This is a normal potassium level (3.5–5.0 mmol/L) and indicates successful treatment.
B. Serum glucose 58 mg/dL: IV insulin drives potassium into cells, lowering serum potassium. However, insulin also lowers blood glucose, which can lead to hypoglycemia (glucose <70 mg/dL). Hypoglycemia is the primary adverse effect of IV insulin therapy.
C. Serum sodium 138 mEq/L: This is a normal sodium level (135–145 mEq/L) and not an adverse effect.
D. Calcium level of 100 mg: Calcium is not directly affected by IV insulin therapy.
Correct Answer is A
Explanation
A. The development of malignant hyperthermia: Malignant hyperthermia (MH) is a life-threatening reaction to certain anesthetics (e.g., succinylcholine, halothane). It causes rapid muscle breakdown, severe hyperthermia, tachycardia, muscle rigidity, and metabolic acidosis. Immediate treatment with IV dantrolene and cooling measures is required.
B. The development of fluid volume excess: Fluid overload may cause hypertension and pulmonary edema but does not cause sudden high fever.
C. The development of an allergic response to the pain medication: Drug allergies typically present with rash, itching, or anaphylaxis, not extreme fever.
D. The development of an infection. Post-op infections usually develop over several days, not immediately in PACU.
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