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 ["A"]
Explanation
A. Protein-calorie malnutrition can lead to decreased tissue integrity and delayed wound healing, increasing the risk of pressure ulcer development due to compromised nutritional status.
B. Diabetes, especially when uncontrolled, can lead to poor circulation and neuropathy, which increases the risk of pressure ulcers. Hyperglycemia can also impair wound healing and compromise the immune response, further contributing to the risk.
C. Edema increases pressure on the skin and underlying tissues, impairing circulation and increasing the risk of pressure ulcers, especially in areas where there is constant pressure or friction against surfaces.
D. A client with postoperative delirium is not necessarily at risk of delirium.
E. A client post cardiac catheterization and already ambulating is not at risk of pressure sores
Correct Answer is A
Explanation
A. Reporting any worsening or unrelieved pain is important because increasing or unrelieved pain could indicate complications such as inadequate immobilization, pressure sores, or compartment syndrome. Prompt reporting allows for timely intervention and prevention of further complications
B. Movement of the affected leg could disrupt the alignment of the bones and impede the healing process. Immobilization is essential for bone healing in a fiberglass cast. However, reporting features of compartment syndrome is priority.
C. Patients should be advised not to insert anything under the cast and instead use other methods such as blowing cool air under the cast or gently tapping on the outside of the cast to relieve itching.
D. Using a blow dryer on a moderate heat setting can help speed up the drying process of the cast after it gets wet. However, it's important to ensure that the heat is not too high to avoid causing burns or softening the cast material excessively.
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