Nokea
A client who has just returned from surgery is shivering uncontrollably. What is the best action for the nurse to take?
- A. Offer the client a warm blanket
- B. Apply warm blankets and monitor the client's temperature
- C. Place a warm blanket in the client's bed before transferring the client from the stretcher
- D. Administer a prescribed muscle relaxant
Correct Answer: B
Rationale: Applying warm blankets and monitoring the client's temperature is the best action to manage postoperative shivering. Shivering after surgery can be a common response due to factors like exposure to cold, pain, or anesthesia effects. Providing warmth through blankets can help regulate the client's body temperature and alleviate shivering. Monitoring the client's temperature is essential to ensure it returns to a normal range. Option A is not as comprehensive as option B, which includes both providing warmth and monitoring the client. Option C is incorrect as it focuses on preparing the bed rather than addressing the client's immediate need for warmth. Option D is not appropriate without further assessment or prescription for a muscle relaxant to address shivering.
You may also like to solve these questions
A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight-based heparin protocol are initiated. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Evaluate blood clotting factors daily.
- B. Encourage incentive spirometry use.
- C. Administer pain medication as needed.
- D. Monitor for signs of bleeding.
Correct Answer: A
Rationale: Evaluating blood clotting factors daily is crucial when a client is on heparin therapy to monitor for potential complications such as bleeding or clotting issues. This monitoring helps ensure that the heparin dose is within the therapeutic range and reduces the risk of bleeding or clotting complications. Encouraging incentive spirometry use is beneficial for preventing atelectasis and improving lung function, but in this scenario, monitoring blood clotting factors takes precedence. Administering pain medication as needed is important for the client's comfort but is not the priority in managing a pulmonary embolism. Monitoring for signs of bleeding is important due to heparin therapy, but evaluating blood clotting factors provides more specific information on the client's response to treatment.
A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which laboratory value is most concerning?
- A. Serum potassium of 6.5 mEq/L
- B. Serum bicarbonate of 18 mEq/L
- C. Serum glucose of 350 mg/dl
- D. Serum sodium of 135 mEq/L
Correct Answer: A
Rationale: A serum potassium level of 6.5 mEq/L is concerning in a client with COPD exacerbation as it may lead to life-threatening arrhythmias, requiring immediate intervention. Hyperkalemia can cause cardiac arrhythmias, which pose a significant risk to the patient's life. Options B, C, and D are not typically associated with immediate life-threatening risks in the context of a COPD exacerbation.
A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?
- A. Perform an otoscopic examination
- B. Measure the child's abdominal girth
- C. Collect a urine specimen for routine urinalysis
- D. Obtain a blood specimen for serum electrolytes
Correct Answer: C
Rationale: Collecting a urine specimen for routine urinalysis is the next appropriate intervention. The symptoms described, including facial edema and tea-colored urine, are indicative of glomerulonephritis, a condition affecting the kidneys. A urine specimen can help assess renal function and the presence of blood and protein in the urine, which are common in glomerulonephritis. Performing an otoscopic examination (Choice A) is not relevant to the presenting symptoms. Measuring the child's abdominal girth (Choice B) is not necessary at this point as it does not directly address the urinary symptoms. Obtaining a blood specimen for serum electrolytes (Choice D) may provide information about electrolyte imbalances but is not the most appropriate initial step in this case.
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which clinical finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Heart rate of 110 beats per minute
- C. Blood pressure of 140/90 mmHg
- D. Respiratory rate of 24 breaths per minute
Correct Answer: A
Rationale: A fever of 100.4°F is a clinical finding that requires immediate intervention in a client with ESRD scheduled for hemodialysis. Fever may indicate an underlying infection, which can be severe in individuals with compromised renal function. Prompt assessment and treatment are essential to prevent worsening of the infection and potential complications. Heart rate, blood pressure, and respiratory rate are also important parameters to monitor in clients with ESRD, but in this scenario, the fever takes precedence due to its potential to indicate a critical condition that requires urgent attention.
A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?
- A. 'I will take my medication in the morning before breakfast.'
- B. 'I should avoid eating foods high in potassium.'
- C. 'I should change positions slowly to avoid dizziness.'
- D. 'I should avoid abrupt discontinuation of the medication.'
Correct Answer: B
Rationale: The correct answer is B: 'I should avoid eating foods high in potassium.' This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.