Fundamentals Question #33

Question

A client 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 client 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:

      This answer is correct because when a client is recovering from surgery and vital signs are relatively normal except an elevated temperature, the client has shivering, and is struggling to breathe, infection is suspected. The priority action is to support the oxygenation, meet the client’s immediate need of shivering, and notify the surgeon. Blood work and other laboratory tests may need to be ordered, then antibiotics started to keep the infection from becoming sepsis. The sites most commonly affected by infection are blood stream, urinary tract, surgical wounds and the lungs. Any symptoms of infection should be reported immediately.

  2. Place ice bags under the client's arms and record the vital signs
    • Rationale:

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

  3. Adjust the thermostat in the room to make it warmer and provide a warm beverage
    • Rationale:

      This answer is not correct because adjusting the thermostat in the room to make it warmer and provide a warm beverage may make the client more uncomfortable and nauseated. A temperature that is higher than expected in the first 48 hours after surgery are concerning for nosocomial infections and should be reported to the surgeon. The client will need to be supported with oxygen, monitoring, and comfort measures to help with the shivering.

  4. Alert the rapid response team and notify the surgeon
    • Rationale:

      This answer is not correct because the rapid response team does not need to be alerted. This is not an emergency but needs to be reported to the surgeon promptly. A temperature that is higher than expected in the first 48 hours after surgery are concerning for nosocomial infections and should be reported to the surgeon. The client will need to be supported with oxygen, monitoring, and comfort measures to help with the shivering.

       

Overview

When a client is recovering from surgery and vital signs are relatively normal except an elevated temperature, the client has shivering, and is struggling to breathe, infection is suspected. The priority action is to support the oxygenation, meet the client’s immediate need of shivering, and notify the surgeon.

 

Explanation

Learning Outcomes

Nosocomial infections are hospital acquired infections that are newly acquired once a client is admitted to the hospital. They occur within 48 hours of the client’s admission to the hospital, 3 days after discharge, or within 30 days of an operation. At the time of admission these infections were not incubating or present. The sites most commonly affected by infection are blood stream, urinary tract, surgical wounds and the lungs. If a client has an elevated temperature, with shivering and dyspnea, the nurse should support oxygenation as ordered, apply a warm blanket, and contact the surgeon. Blood work and other laboratory tests may need to be ordered, then antibiotics started to keep the infection from becoming sepsis. Transmission of pathogens in nosocomial infections is the fault of those the client comes in contact with and all efforts must be made to interrupt that transmission of pathogens. One of the most effective ways to decrease the spread of nosocomial infection is washing hands.

Test Taking Tip

The rapid response team is only contacted if there has been a sudden emergency, generally with a visitor. The medical response team is a group of experts that might be called upon if the client was having an emergency, but this client’s condition is not emergent. Treating the client with prescribed oxygenation, providing comfort to relax and calm the client, and contacting the surgeon to report the findings is most important.

Video Rationale