The nurse is caring for a client who has had an upper G.I. endoscopy. The client's vital signs must be taken every 30 minutes for two hours after the procedure. The nurse assigns an unlicensed assistant to take the vital signs. Two hours later, the assistant reports to client who was previously afebrile has now developed a temperature of 101.8°F. What should the nurse do in response to this reported data by the unlicensed assistant?

Promptly assess the client for a potential perforation

Tell the assistant to change thermometers and retake the temperature

Plan to give the client acetaminophen the lower temperature

Ask the assistant to bathe the client with tap water

Answer and Explanation

The Correct Answer is A

A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.

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Correct Answer is D

Explanation

A. Inflammation of the esophagus (esophagitis) may cause symptoms like heartburn or dysphagia, but it would not explain the sudden, sharp pain or rigid abdomen seen with a perforated ulcer.
B. An intestinal obstruction can cause abdominal pain and distension, but the rigid, board-like abdomen is more characteristic of peritonitis from a perforated ulcer, not an obstruction.
C. Additional ulcers could cause pain and bleeding, but they would not explain the sudden, sharp pain and rigid abdomen that typically result from perforation.
D. The sudden onset of sharp, severe pain in the mid epigastric area, along with a rigid, board-like abdomen, are hallmark signs of a perforated ulcer, which causes peritonitis. This is a medical emergency, as the perforation allows gastric contents to leak into the peritoneal cavity, leading to widespread infection.

A. Administer a soap-suds enema to cleanse the colon. B. Soak in a sitz bath for 20 min after each stool. C. Wipe perianal area with warm water and apply a barrier cream. D. Cleanse with antimicrobial scrub and vigorously dry.

Correct Answer is C

Explanation

A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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