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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Crushing zolpidem to increase absorption is inappropriate because it is a controlled-release medication. Crushing the tablet would disrupt the controlled-release mechanism, leading to rapid absorption, increased side effects, and potentially dangerous consequences.
Choice B rationale
Taking zolpidem before bedtime is correct because it is a medication prescribed for insomnia. It helps the patient fall asleep more quickly by acting on the central nervous system to induce sleep, and it should be taken when the patient is ready to sleep.
Choice C rationale
Administering zolpidem with a meal is not recommended. Food can delay the absorption of the medication, reducing its effectiveness in helping the patient fall asleep promptly.
Choice D rationale
Storing zolpidem at room temperature is correct, but it is not a critical point of patient education. The emphasis should be on taking the medication as prescribed and understanding its purpose and potential side effects.
Correct Answer is A
Explanation
Choice A rationale
Reporting the client's jaw pain to the healthcare provider is crucial because jaw pain is a potential symptom of osteonecrosis of the jaw (ONJ), a rare but serious side effect of bisphosphonates like alendronate. ONJ involves the death of bone tissue in the jaw, leading to significant complications. Early intervention and management are essential to prevent further deterioration and address any underlying issues.
Choice B rationale
Determining how the client is administering the medication is important but not the immediate priority when addressing jaw pain, which could indicate a serious complication. Ensuring proper administration can prevent future issues but does not address the immediate concern of potential ONJ.
Choice C rationale
Advising the client to gargle with warm salt water twice daily may provide temporary relief from minor oral discomfort but is not appropriate for addressing potential osteonecrosis of the jaw. This suggestion does not address the underlying cause of jaw pain in a client taking bisphosphonates.
Choice D rationale
Confirming that jaw pain is a common symptom of osteoporosis is incorrect. While musculoskeletal pain can be associated with osteoporosis, jaw pain in a client taking alendronate may indicate osteonecrosis of the jaw, a serious condition requiring prompt medical attention.
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