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 B
Explanation
B. If the patient expresses confusion or uncertainty about the surgical procedure, the nurse should notify the surgeon or appropriate healthcare provider promptly. The surgeon may need to revisit the discussion with the patient, clarify any misunderstandings, and answer any questions to ensure informed consent.
A. This option involves the nurse providing the patient with a comprehensive explanation of the planned surgical procedure, including the purpose, risks, benefits, and alternatives. That however, is the role of the provider.
C. While the operating room nurse may have knowledge about the planned surgical procedure, it is ultimately the responsibility of the surgeon or healthcare provider performing the procedure to ensure that the patient understands and consents to the surgery.
D. Administering preoperative antibiotics and managing sedative medications are important aspects of preoperative care but are not directly related to addressing the patient's concerns about understanding the planned surgical procedure.
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