A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next?
Hold opioid analgesics until the patient is warmer.
Notify the anesthesia care provider.
Cover the patient with a warm blanket.
Give acetaminophen 650 mg suppository rectally.
The Correct Answer is C
C. Covering the patient with a warm blanket is an appropriate initial intervention to address the patient's hypothermia and shivering. Heat conservation measures, such as using blankets or warming devices, help raise the patient's body temperature and alleviate shivering.
A. While shivering and a low body temperature (hypothermia) can be common postoperative complications, holding opioid analgesics may not directly address the underlying cause of the shivering or hypothermia.
B. Notifying the anesthesia care provider is a prudent action, especially if the patient's shivering and hypothermia are suspected to be related to intraoperative factors such as inadequate warming or anesthesia-induced temperature dysregulation. However, this is not the immediate action.
D. Acetaminophen is not typically indicated as the initial treatment for hypothermia or shivering. While acetaminophen can help reduce fever and discomfort, rectal suppositories may not provide rapid temperature elevation or relief from shivering.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This test is known as Phalen's maneuver. It involves holding the wrist in flexion for 60 seconds or more to compress the median nerve, which runs through the carpal tunnel in the wrist. Reproduction of symptoms, such as numbness and tingling, during this maneuver is considered a positive sign for carpal tunnel syndrome.
A. Flexing the arm at the elbow doesn't directly assess for carpal tunnel syndrome. This movement primarily involves the elbow joint and the muscles of the upper arm.
C. Extending the arm upward doesn't directly assess for carpal tunnel syndrome. This movement primarily involves the shoulder joint and muscles of the upper arm.
D. Holding the arm straight doesn't directly assess for carpal tunnel syndrome. This movement primarily involves the elbow joint and muscles of the upper arm.
Correct Answer is D
Explanation
D. Tachypnea is a classic early manifestation of fat embolism syndrome. Fat emboli can travel to the lungs and obstruct blood flow, leading to respiratory distress and hypoxemia. Tachypnea is the body's response to hypoxemia, as it attempts to increase oxygen intake by breathing more rapidly.
A. Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), but it is not typically an early manifestation of fat embolism syndrome.
B. tachycardia is more commonly seen due to the body's response to decreased oxygen levels and increased demand on the cardiovascular system.
C. Hypertension is not typically associated with fat embolism syndrome. Instead, hypotension can occur due to decreased cardiac output and systemic vasodilation in severe cases of fat embolism syndrome.
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