Nokea
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do in response to this reported assessment data?
- A. Promptly assess the client for potential perforation.
- B. Tell the assistant to change thermometers and retake the temperature.
- C. Plan to give the client acetaminophen (Tylenol) to lower the temperature.
- D. Ask the assistant to bathe the client with tepid water.
Correct Answer: A
Rationale: A sudden fever after an upper GI endoscopy may indicate a serious complication, such as perforation, requiring immediate nursing assessment. The other options delay appropriate intervention or do not address the potential severity of the situation.
You may also like to solve these questions
A client with cancer is admitted with suspected disseminated intravascular coagulation (DIC). Which laboratory finding supports this diagnosis?
- A. Prolonged prothrombin time (PT).
- B. Elevated hemoglobin.
- C. Normal platelet count.
- D. Decreased D-dimer.
Correct Answer: A
Rationale: DIC causes abnormal clotting and bleeding, leading to a prolonged prothrombin time (PT) due to consumption of clotting factors, supporting the diagnosis.
The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
- A. Decreased blood flow
- B. Increased blood flow
- C. Slow blood flow
- D. Thrombus formation
Correct Answer: A
Rationale: The hallmark of PVD is decreased blood flow due to arterial narrowing from atherosclerosis or other occlusive processes. This reduced flow causes ischemia, leading to claudication (pain during walking) that is relieved by rest. Increased or slow blood flow and thrombus formation are not the primary characteristics.
Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
- A. A 60-year-old man with a hiatal hernia.
- B. A 36-year-old woman with three children.
- C. A 50-year-old woman caring for a spouse with cancer.
- D. A 60-year-old woman with osteoarthritis.
Correct Answer: C
Rationale: The 50-year-old caring for an immunocompromised spouse is the highest priority for influenza vaccination to prevent transmission. Others have lower risk profiles.
A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide (Orinase). When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions?
- A. Potentiating the action of insulin.
- B. Lowering the renal threshold of glucose.
- C. Stimulating insulin release from functioning beta cells in the pancreas.
- D. Combining with glucose to render it inert.
Correct Answer: C
Rationale: Tolbutamide, a sulfonylurea, stimulates insulin release from pancreatic beta cells, helping to lower blood glucose levels in type 2 diabetes.
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should be necessary:
- A. Family history.
- B. Lifestyle choices.
- C. Age.
- D. Menopause or hormonal events.
Correct Answer: C
Rationale: Age is the most significant risk factor for cancer, as the incidence of most cancers increases with advancing age due to cumulative genetic and environmental damage.