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 C

Explanation

A. Analyze past hurts and resentments to identify the source. This strategy is more appropriate for clients in therapy to address past trauma. It is not the immediate focus for managing anxiety.
B. Concentrate on and ventilate emotions when distressed. While expressing emotions is important, it might not be the most effective strategy for generalized anxiety disorder, as it can sometimes exacerbate anxiety.
C. Focus on small achievable tasks, not taxing problems. This approach helps the client manage anxiety by breaking down large tasks into manageable steps, which reduces the overwhelming feelings associated with generalized anxiety disorder.
D. Relax and reduce the amount of effort to solve the problem. Relaxation is useful, but focusing on small, achievable tasks is a more effective way to manage anxiety in this scenario.

A. Exenatide acts in the same way as insulin in lowering blood glucose. B. Notify your healthcare provider if you start having abdominal pain. C. There are no precautions about taking exenatide with other medications. D. Inject exenatide within 30 minutes before or after a meal.

Correct Answer is B

Explanation

A. Exenatide does not act exactly the same as insulin. It is a glucagon-like peptide-1 (GLP-1) receptor agonist, not insulin.

B. Notify your healthcare provider if you start having abdominal pain is important because abdominal pain is a known side effect of exenatide and may indicate a more serious issue like pancreatitis, which needs to be addressed promptly.

C. There are precautions when taking exenatide with other medications, especially those that affect gastrointestinal motility or glucose levels, so this statement is incorrect.

D. Exenatide should be injected within 60 minutes before a meal, not 30 minutes before or after, to optimize its effectiveness.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

Correct Answer is C

Explanation

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

Correct Answer is B

Explanation

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