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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Applying ice to the affected knee is a common postoperative instruction after arthroscopic knee surgery. Ice helps reduce swelling, inflammation, and pain in the surgical area. It is usually recommended to apply ice intermittently for short periods during the first 24 to 48 hours following surgery.

A. Keeping the leg in a dependent position, where it is hanging down, is not typically recommended following arthroscopic knee surgery.

C. Complete bedrest for the first 24 hours after arthroscopic knee surgery is not typically necessary or recommended. Early mobilization and gentle range of motion exercises are usually encouraged to prevent complications such as blood clots and joint stiffness.

D. These exercises help restore joint mobility, prevent stiffness, and promote healing of the surgical site. However, the timing and specific exercises should be guided by the surgeon's instructions and individual patient factors.

A. Assess the temperature of the affected extremity. B. Adjust the prescribed weights every shift. C. Examine the skin under the traction splint. D. Monitor peripheral pulses in the affected extremity. E. Position weights against the foot of the bed.

Correct Answer is ["A","C","D"]

Explanation

A. Assessing the temperature of the affected extremity is important because changes in temperature could indicate circulation problems, which are a concern with traction. Assessing temperature helps in detecting any potential issues early on.

C. Skin integrity is crucial as traction can put pressure on the skin, potentially leading to pressure ulcers or skin breakdown. Regular examination helps in detecting any signs of skin irritation or breakdown early so that appropriate interventions can be initiated.

D. Traction can sometimes impede circulation to the affected limb, leading to complications such as compartment syndrome. Monitoring peripheral pulses helps in detecting any circulation problems promptly.

B. Adjusting the prescribed weights is not typically within the nurse's scope of practice, as the weights are determined by the physician and should not be altered without specific orders.

E. Positioning the weights against the foot of the bed is incorrect; they should hang freely to maintain effective traction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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