94. Following general anesthesia for a hip replacement, an elderly client's vital signs are: P 80, R 14, blood pressure 110/78 mm Hg; O2 Sat 100% on 40% mask; pain 2/10. The client is shivering and complains of being cold. The first nursing priority should be to:
Test-Taking Tip
Think patient comfort. Care for the client first, and then check the temperature.
Content Area: Geriatrics, Musculoskeletal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is incorrect because, although the oxygen saturation is 100%, shivering does increase oxygen consumption and supplemental O2 will be needed, not removed. Answer 2 is incorrect because warm blankets need to be applied to treat the complaints and shivering regardless of the client's temperature. Answer 3 is correct because shivering increases oxygen consumption. Hypothermia associated with the perioperative period may cause arrhythmia, clotting problems, and impaired wound healing. Answer 4 is incorrect because the pain level is low at 2/10 and does not require treatment.
