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. Elevated serum potassium levels are not a specific finding related to gastric ulcers. They may be seen with other conditions such as kidney dysfunction or the use of certain medications (e.g., diuretics).
B. An increased white blood cell count is often associated with infection or inflammation but is not specific to gastric ulcers.
C. Mid epigastric pain that worsens with eating is more characteristic of duodenal ulcers, not gastric ulcers.
D. Epigastric pain that worsens with eating is a hallmark symptom of a gastric ulcer. This pain is typically aggravated by food intake due to the increased acid production in the stomach during digestion.
Correct Answer is ["0.4"]
Explanation
Volume (mL) = Desired dose (mg) / Concentration (mg/mL)
In this case:
- Desired dose = 35 mg
- Concentration = 75 mg/mL
Plugging the values into the formula:
- Volume = 35 mg / 75 mg/mL = 0.4 mL
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