Author Question: The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been ... (Read 107 times)

melly21297 · **on:** Jun 25, 2018

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5 F (35.8 C). Which action should the nurse take?

a. Cover the patient with a warm blanket and put on socks.
b. Notify the anesthesia care provider about the temperature.
c. Avoid the use of opioid analgesics until the patient is warmer.
d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.

Question 2

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

a. The right calf is swollen, warm, and painful.
b. The patient's temperature is 100.3 F (37.9 C).
c. The 24-hour oral intake is 600 mL greater than the total output.
d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

Bison · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider, unless the patient continues to be hypothermic after active rewarming.

Answer to Question 2

ANS: A
The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3 F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.