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 D
Explanation
D. Petechiae, which are small red or purple spots caused by bleeding under the skin, are a classic manifestation of fat embolism syndrome. They typically appear on the upper chest, axilla (armpit), and conjunctiva of the eyes. Petechiae result from the occlusion of small blood vessels by fat globules, leading to microvascular bleeding.
A Paresthesia distal to the fracture site is not a typical manifestation of fat embolism syndrome. Instead, paresthesia may suggest nerve compression or injury related to the fracture itself rather than fat emboli.
B Fever is not a specific manifestation of fat embolism syndrome. While fever can occur with various types of infections or inflammatory conditions, it is not a hallmark symptom of fat embolism.
C Swelling of the calf can occur with conditions such as deep vein thrombosis (DVT), which is a potential complication of lower limb fractures. However, it is not a typical manifestation of fat embolism syndrome.
Correct Answer is D
Explanation
D. Quadriceps setting exercises help strengthen the quadriceps muscles, which play a crucial role in knee stability and function. These exercises can be initiated early in the postoperative period and are typically part of the rehabilitation program following a partial meniscectomy.
A. Full weight bearing may place excessive stress on the knee joint and hinder the healing process.
B. Heat therapy is generally not recommended immediately after a partial meniscectomy. Heat can increase blood flow and swelling, which may exacerbate pain and inflammation in the early postoperative period.
C. Range of motion (ROM) exercises help prevent stiffness and promote flexibility in the knee joint after surgery. However, these exercises should not be initiated immediately.
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