Answer to Question 1
ANS: A
A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature.
Answer to Question 2
ANS: D
In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.
Patient teaching: nose and sinus assessment
Algorithm for assessing a patient at risk for self-directed violence.
Promoting Adherence in the Older Adult Patient
A histologic slide showing the sponge-like architecture of a patient with Creutzfeldt-Jakob Disease.
Medical Gymnasts Assist Patient in Performing Movements, 1909.