Free Trial #15

Question

A patient recovering from surgery has a BP of 138/88 mm Hg, pulse 72 bpm; respiratory rate of 28 breaths/min; and temperature 103.2 F. The patient is also shivering and struggling to breath. Which nursing actions are a priority?

Answers

  1. Apply a warm blanket, continue oxygen as prescribed and notify the surgeon
    • Rationale:
  2. Place ice bags under the patient’s arms and record the vital signs
    • Rationale:
  3. Adjust the thermostat in the room to make it warmer and provide a warm beverage
    • Rationale:
  4. Alert the rapid response team and notify the surgeon
    • Rationale:

Overview

Explanation

The correct option is A. Temperature that is higher than expected in the first 48 hours after surgery are concerning for nosocomial infections and should be reported. The patient will need to be supported with oxygen, monitoring, and comfort measures to help with the shivering. Ice pack/bags are used for heat stroke but not in the postoperative period where it could increase the amount of shivering.

Because making the room warmer and a warm beverage might slightly make the patient more comfortable but is not the priority intervention to alleviate the problem. The rapid response team is not needed.

Learning Outcomes

Test Taking Tip

Video Rationale