Page the admitting anesthesiologist STAT.

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.

Recheck all vital signs including core temperature.

Apply oxygen via nasal prongs at 4 L/minute.

Continue to monitor vital signs every hour.

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

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Rechecking all vital signs, including core temperature, is essential to assess the client's overall status and identify any changes that may indicate a worsening condition or complications such as infection.

Choice B rationale

Applying oxygen via nasal prongs at 4 L/minute helps ensure adequate oxygenation, which is crucial for patients who may be experiencing postoperative complications, including fever and increased metabolic demand.

Choice C rationale

Continuing to monitor vital signs every hour is important to detect any further changes in the patient's condition and provide timely interventions if needed. Frequent monitoring allows for close observation of trends.

Choice D rationale

Exposing the client's extremities and applying ice packs to the axilla can help reduce fever by promoting heat loss. This intervention is beneficial in managing elevated body temperature and preventing complications associated with hyperthermia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.

Choice B rationale

Identifying support systems in the client's life is crucial for addressing the emotional and psychological impact of being HIV positive and a victim of rape. Support systems, such as family, friends, or support groups, can provide the necessary emotional support and practical assistance to help the client cope with the challenges.

Choice C rationale

Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.

Choice D rationale

Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.

A. Lathering using a circular movement. B. Turning the water off using bare hands. C. Washing for a total of 20 seconds. D. Holding hands below elbows when rinsing. E. Holding hands below elbows when rinsing.

Correct Answer is B

Explanation

Choice A rationale

Lathering using a circular movement is an effective handwashing technique. This method ensures thorough coverage of all surfaces of the hands, including areas that are often missed, such as between the fingers and under the nails. The friction generated by the circular motions helps dislodge dirt, bacteria, and viruses from the skin. Proper lathering is a crucial step in reducing the microbial load on the hands and preventing the spread of infections.

Choice B rationale

Turning the water off using bare hands contaminates the hands after they have been washed. This action can reintroduce bacteria or viruses from the faucet handle back onto the clean hands, negating the benefits of handwashing. Proper hand hygiene protocol recommends using a paper towel or elbow to turn off the water to maintain the cleanliness achieved by washing. This step is critical in breaking the chain of infection transmission.

Choice C rationale

Washing hands for a total of 20 seconds is in line with the recommended guidelines from health organizations like the CDC. This duration is considered sufficient to effectively remove soil, dirt, and transient microorganisms from the skin. It allows enough time for the soap to act on contaminants and for mechanical action to dislodge them. Adhering to this time frame is an essential component of effective hand hygiene practices.

Choice D rationale

Holding hands below the elbows when rinsing ensures that water flows from the wrists down to the fingertips, effectively washing away soap and contaminants. This technique prevents recontamination of the hands by keeping the direction of water flow from the cleanest to the dirtiest areas. Proper rinsing is a key aspect of hand hygiene, ensuring that all soap residues, along with any remaining microorganisms, are thoroughly removed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse observes an unlicensed assistive personnel (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is B

Explanation

A nurse is caring for a 59-year-old male client in the intermediate care unit. Exhibits Which of the following findings requires the nurse's immediate attention?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment. Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.