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. A comminuted fracture involves the bone being broken into multiple pieces or fragments. This description matches the scenario of the fractured tibia being splintered into several pieces.

A. An impacted fracture occurs when the bone fragments are driven into each other, causing shortening of the bone. This description does not match the scenario provided.

C. An oblique fracture occurs when the fracture line runs diagonally across the bone shaft. This description does not match the scenario provided.

D. A transverse fracture occurs when the fracture line is perpendicular to the long axis of the bone. This description does not match the scenario provided.

A. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal. B. Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. C. Consult with the health care provider about using a different treatment protocol to control the patient's pain. D. Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

Correct Answer is C

Explanation

C. This option is appropriate as the current treatment protocol is not effectively managing the patient's pain. The nurse can collaborate with the healthcare provider to reassess the patient's pain management needs and explore alternative strategies or adjustments to the PCA regimen.

A. This approach may lead to overmedication and increase the risk of adverse effects such as respiratory depression or sedation.

B. Requesting a bolus dose when the patient awakens with pain could be a part of the solution, but it should be carefully evaluated within the context of the overall pain management plan.

D. Administering scheduled doses of morphine from the PCA machine without the patient's input or based solely on time intervals is not recommended.

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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 caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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