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 D
Explanation
A. 3% sodium chloride is a hypertonic solution used to treat severe hyponatremia and should not be used as a substitute for TPN.
B. Lactated Ringer's is an isotonic solution typically used for fluid resuscitation, but it lacks the necessary components (glucose, amino acids) that are found in TPN.
C. 0.9% sodium chloride is an isotonic saline solution and can be used for hydration, but it does not provide the calories and nutrients that the client is receiving through TPN.
D. Dextrose 10% in water is the best choice in this scenario. It provides glucose for energy and can help maintain blood sugar levels until the next TPN solution is available. It is commonly used as a temporary substitute for TPN to prevent hypoglycemia.
Correct Answer is B
Explanation
A. "Moon phase" is not a correct term related to prednisone use. The term "moon face" refers to the round, puffy face that can result from prolonged steroid use, which is a side effect, but it is not something the patient needs to notify the healthcare provider about unless it is accompanied by other severe symptoms.
B. Taking the steroid medication as prescribed is essential. Prednisone is a corticosteroid, and missing doses or abruptly stopping the medication can lead to complications such as adrenal insufficiency. It's important for the client to adhere to the prescribed regimen to manage inflammation and minimize the risk of side effects.
C. Steroids like prednisone can cause increased blood glucose levels, so it's important for the client to monitor blood glucose more frequently. If blood glucose levels exceed 150 mg/dL, they should notify their healthcare provider, but this is not the immediate management strategy for this scenario.
D. Prednisone should be taken with food to reduce gastrointestinal irritation, not on an empty stomach. Taking it without food can increase the risk of stomach upset and ulcers, particularly in patients with inflammatory bowel disease.
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