Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

Expose client's extremities and apply ice packs to axilla.

Recheck all vital signs including core temperature.

Continue to monitor vital signs every hour.

Apply oxygen via nasal prongs at 4 L/minute.

Page the admitting anesthesiologist STAT

Answer and Explanation

Correct Answer : B,D,E

A. Ice packs can be used but are not the first priority.
B. Rechecking core temperature confirms the severity of hyperthermia.
C. Monitoring hourly is insufficient for a rapidly rising temperature.
D. Oxygen helps prevent hypoxia from hypermetabolic states.
E. Malignant hyperthermia is a medical emergency requiring immediate intervention.

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Correct Answer is ["A","B","E","F","H"]

Explanation

Heart Rate: 128 beats/min (Sinus Tachycardia): Sinus tachycardia can be a compensatory response to hypovolemia, internal bleeding, or pain. Given the liver and spleen lacerations identified on the CT scan and blood in the peritoneum, tachycardia may indicate ongoing hemorrhage or hypoperfusion.

Blood Pressure: 90/79 mmHg (Narrow Pulse Pressure): A pulse pressure of less than 40 mmHg suggests inadequate perfusion and possible hemorrhagic shock. The systolic blood pressure (90 mmHg) is at the lower limit of normal, but the diastolic pressure (79 mmHg) is elevated, which can indicate compensatory vasoconstriction due to hypovolemia. Immediate fluid resuscitation or blood transfusion may be required to prevent worsening shock.

Temperature: 96.9°F (36.1°C): Trauma clients, especially those with hemorrhage, are at risk for trauma triad of death (hypothermia, acidosis, coagulopathy) due to massive fluid shifts and blood loss. Even mild hypothermia can impair coagulation and worsen bleeding, requiring active warming measures (e.g., warm IV fluids, heated blankets).

Abdominal Ecchymosis and Hematoma: Significant bruising around the surgical dressing suggests ongoing internal bleeding or vascular injury.

Close monitoring is needed to assess for expanding hematoma, increased abdominal distension, or hemodynamic instability.

A. Give diphenhydramine prep for intravenous pyelogram. B. Obtain clean catch urine for culture and sensitivity. C. Force oral fluids to 2,000 mL/24 hours. D. Initiate broad spectrum IV antibiotic as secondary infusion. E. Collect a serum sample for hemoglobin and hematocrit.

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

Explanation

A. Diphenhydramine is unnecessary for diagnosing pyelonephritis.
B. Urine culture confirms bacterial infection and guides antibiotic therapy.
C. Forcing fluids may help but is not the priority over antibiotics and cultures.
D. Broad-spectrum IV antibiotics are critical to treat systemic infection.
E. Hemoglobin and hematocrit are not priority tests for pyelonephritis.

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Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","E","F","H"]

Explanation

An adult is admitted with acute flank pain, a 102° F (38.9° C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.

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

Explanation

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