HESI RN Med surg proctored exam 2
The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a heart rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mm Hg. Which action should the nurse implement?
Explanation & Rationale
Choice A reason: Raising the head of the bed is not related to the low temperature.Choice B reason:The correct answer is b) because a tympanic temperature of 94.6°F is unexpectedly low and may be due to improper measurement. Rechecking with a different method ensures accuracy.Choice C reason: Frequent blood pressure monitoring is important but not the first action for a low temperature reading.Choice D reason: Asking the client to cough and deep breathe is beneficial postoperatively but does not address the low temperature concern.
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