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Patient Data

Exhibits

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

Apply warm blankets

Administer an antipyretic

Place ice packs around the client's head

Check the temperature of the humidified oxygen attached to the ventilator

Instill warm fluids in the nasogastric tube

Microwave a pack of gauze and distribute across the body

Administer intravenous fluids with a rapid infuser

Use a fluid warmer for intravenous fluids

Answer and Explanation

Correct Answer : A,D,E,G,H

A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.

B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.

C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.

D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.

E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.

F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.

G. Administer intravenous fluids with a rapid infuser: Warm IV fluids given rapidly restore circulating volume in trauma clients and also help increase core body temperature, addressing both shock and hypothermia.

H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.

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Correct Answer is D

Explanation

A. Palpate flank area: Flank assessment may help detect kidney tenderness or infection but is not the primary focus for routine suprapubic catheter care unless complications are suspected.

B. Assess perineal area: The suprapubic catheter bypasses the perineal route, so routine perineal assessment is less critical for catheter management, though general hygiene remains important.

C. Measure abdominal girth: Abdominal girth measurement is useful for detecting ascites or abdominal distention but is not directly relevant to monitoring a suprapubic catheter.

D. Observe insertion site: Regular inspection of the catheter insertion site is essential to detect signs of infection, leakage, irritation, or improper placement. This assessment helps ensure catheter function and prevents complications, making it the priority during home visits.

A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. C. The client with an obstruction of the large intestine who is experiencing abdominal distention. D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid.

Correct Answer is B

Explanation

A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds: Paralytic ileus is common postoperatively and, while concerning, is usually not immediately life-threatening.

B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity: Abdominal rigidity suggests possible bowel ischemia or perforation, which are surgical emergencies. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

C. The client with an obstruction of the large intestine who is experiencing abdominal distention: While abdominal distention indicates obstruction, it is not immediately life-threatening unless accompanied by signs of ischemia or perforation.

D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid: NG drainage is expected with small bowel obstruction and indicates decompression is occurring. This is less urgent than a client showing signs of peritonitis.

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Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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Patient data Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

Patient Data

Exhibits

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