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Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Place ice packs around the client's head

Microwave a pack of gauze and distribute across the body

Administer intravenous fluids with a rapid infuser

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Use a fluid warmer for intravenous fluids

Apply warm blankets

Administer an antipyretic

Answer and Explanation

Correct Answer : C,D,E,F,G

A. Place ice packs around the client's head: This is a cooling intervention used for hyperthermia, not for treating hypothermia.
B. Microwave a pack of gauze and distribute across the body: This is unsafe, as microwaved materials can cause burns and do not provide effective heat distribution.
C. Administer intravenous fluids with a rapid infuser: Rapid infusion of warmed IV fluids can help restore core body temperature and prevent further hypothermia.
D. Check the temperature of the humidified oxygen attached to the ventilator: Cold or dry oxygen can contribute to heat loss, so ensuring that the humidified oxygen is warmed is an important step in maintaining normothermia.
E. Instill warm fluids in the nasogastric tube: Lavage with warm fluids via NG tube is an effective method of internal warming for hypothermic patients.
F. Use a fluid warmer for intravenous fluids: Warming IV fluids before administration prevents additional heat loss that could occur if room-temperature fluids are given.
G. Apply warm blankets: Passive external warming using warm blankets is an easy and effective intervention to increase body temperature.
H. Administer an antipyretic: Antipyretics (e.g., acetaminophen, ibuprofen) are used for fevers, not for hypothermia.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Epidural anesthesia, commonly used for pain relief during labor, works by blocking nerve impulses in the lower part of the spine, leading to a decrease in sensation and pain in that area. However, this blockade also affects the sympathetic nerves, which are responsible for regulating blood pressure. When these nerves are blocked, they can cause peripheral vasodilation, which is the widening of the blood vessels in the periphery of the body.

Peripheral vasodilation leads to a decrease in vascular resistance, which can significantly lower blood pressure. This drop in blood pressure, known as hypotension, is a common side effect of epidural anesthesia. Hypotension can reduce the blood flow to vital organs, including the placenta, which may affect fetal oxygenation if not promptly and effectively managed. This necessitates careful monitoring and management, typically involving fluid administration and sometimes the use of medications to maintain stable blood pressure during the administration of epidural anesthesia.

A. Measure the client's vital signs before the client walks. B. Report the onset of any dizziness or light headedness. C. Instruct the client about signs of orthostatic hypotension. D. Offer to assist the client to void prior to walking in the hall. E. Determine if the client needs to have a gait belt applied.

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

Explanation

A. UAPs are trained to take and record vital signs. This ensures the client is stable enough to tolerate ambulation.

B. Reporting dizziness or lightheadedness is essential for ensuring the client's safety during ambulation.

C. Teaching is a nursing responsibility, not delegated to UAPs.

D. Offering assistance to void before ambulating helps reduce the risk of falls and ensures comfort during the walk.

E. UAPs can apply a gait belt if instructed, but determining whether it is needed requires nursing judgment.

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Exhibits The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Drag from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

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

Explanation

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Exhibits According to the lab values, the client has dropdownrelated to dropdownordropdown.

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Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.