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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Green tea, while it contains some caffeine, is generally not considered a significant risk factor for the development of peptic ulcers. It may have protective effects due to its antioxidant properties, unlike substances that directly irritate the stomach lining.
B. Moderate alcohol consumption, such as a glass of wine, may irritate the stomach lining but is not a primary risk factor for peptic ulcers unless excessive drinking occurs. This would not be the most significant factor for ulcer development.
C. NSAID use is a well-established risk factor for peptic ulcers. NSAIDs inhibit the production of prostaglandins, which protect the stomach lining from acid damage. Chronic use of NSAIDs can lead to ulcer formation due to this inhibition.
D. Bulimia can lead to acid reflux or esophageal irritation, but it is not a direct risk factor for the formation of peptic ulcers. The primary risk factors for peptic ulcers include H. pylori infection and the use of NSAIDs.
Correct Answer is A
Explanation
A. The IV tubing for TPN should be changed every 24 hours to prevent infection, as TPN is a high-risk solution for bacterial growth due to its high glucose content. Regular changes help reduce the risk of contamination and complications such as bloodstream infections.
B. The IV site dressing should be changed at least every 48 to 72 hours (or per institutional policy) to maintain aseptic technique and minimize infection risk. Changing the dressing every 4 days may exceed this timeframe and increase the risk of infection.
C. Weighing the client is important to monitor fluid balance, but daily weighing is more typical than every other day for clients receiving TPN. This helps to assess nutritional status and detect potential fluid overload or deficit.
D. Blood glucose levels should be monitored more frequently, typically every 6 hours, because TPN can cause significant fluctuations in blood glucose. Checking every 12 hours would not be adequate for early detection of hyperglycemia or hypoglycemia.
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