Page the admitting anesthesiologist STAT. Following a bowel resection, a client's tympanic temperature was 97.6°F (36.4°C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7°C). Which intervention(s) should the nurse implement? Select all that apply.
Explanation & Rationale
Choice A rationale Rechecking all vital signs, including core temperature, is essential to assess the client's overall status and identify any changes that may indicate a worsening condition or complications such as infection. Choice B rationale Applying oxygen via nasal prongs at 4 L/minute helps ensure adequate oxygenation, which is crucial for patients who may be experiencing postoperative complications, including fever and increased metabolic demand. Choice C rationale Continuing to monitor vital signs every hour is important to detect any further changes in the patient's condition and provide timely interventions if needed. Frequent monitoring allows for close observation of trends. Choice D rationale Exposing the client's extremities and applying ice packs to the axilla can help reduce fever by promoting heat loss. This intervention is beneficial in managing elevated body temperature and preventing complications associated with hyperthermia.