A nurse is collecting data for a client who is postoperative and has an elevated temperature. Which of the following actions should the nurse take first?

Assist the client with dangling off the side of the bed.

Check the condition of the client's surgical incision.

Instruct the client to breathe deeply and cough.

Obtain a prescription to check the client's CBC.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Assist the client with dangling off the side of the bed: Early ambulation is important in the postoperative period to prevent complications such as atelectasis or deep vein thrombosis. However, it is not the first action when an elevated temperature is observed, as the cause of the fever must be assessed first.

B. Check the condition of the client's surgical incision: Inspecting the surgical site addresses a potential source of infection, which is a common cause of postoperative fever. This direct assessment helps determine whether local inflammation, drainage, or other signs of infection are present and guides further intervention.

C. Instruct the client to breathe deeply and cough: Encouraging deep breathing and coughing promotes lung expansion and reduces the risk of atelectasis and pneumonia, other causes of postoperative fever. While beneficial, checking the incision for infection is a more direct and immediate assessment for a common and serious cause of postoperative fever.

D. Obtain a prescription to check the client's CBC: A CBC can provide useful information on infection or inflammation, but obtaining lab orders should come after performing a focused assessment to gather immediate, observable data that may warrant urgent action.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.

B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.

C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.

D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.

A. Ensure the client is aware of the scheduled time for the procedure. B. Make sure the client has been informed about the risks of the procedure. C. Ensure the client receives opioid medication prior to giving consent for the procedure. D. Make sure the client's family agrees to the procedure.

Correct Answer is B

Explanation

Rationale:

A. Ensure the client is aware of the scheduled time for the procedure: While knowing the time of surgery is helpful for preparation, it is not a requirement for informed consent. The key issue is whether the client understands the procedure itself and its implications.

B. Make sure the client has been informed about the risks of the procedure: Before witnessing informed consent, the nurse must confirm that the client has received complete information from the provider about the procedure, including its purpose, risks, benefits, and alternatives. This ensures the client is making an informed decision.

C. Ensure the client receives opioid medication prior to giving consent for the procedure: Administering opioids before consent can impair the client's cognitive ability to understand and voluntarily agree. Consent must be obtained while the client is alert and oriented, prior to any sedating medications.

D. Make sure the client's family agrees to the procedure: Consent is only valid when given by the competent client. Family agreement is not legally required unless the client is unable to consent and a legal surrogate is designated.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data for a client who is postoperative and has an elevated temperature. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is preoperative for a surgical procedure. The nurse should identify that which of the following tasks is outside of their scope of practice?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who is scheduled for surgery. Which of the following steps should the nurse take prior to witnessing informed consent?

Correct Answer is B

Explanation

A nurse is reinforcing teaching for a client who has been treated for alcohol use disorder and is being discharged. Which of the following medications should the nurse anticipate the provider to prescribe for relapse prevention?

A nurse is contributing to the plan of care for a client who has a gambling disorder. Which of the following nursing interventions should the nurse include in the plan of care?

A nurse is caring for a client who has right-sided weakness and difficulty swallowing after a stroke. The nurse should ensure the client has referrals to which of the following members of the interprofessional care team? (Select all that apply.)

A nurse is collecting data from a newborn who was born 24 hr ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

A nurse in a long-term care facility is making client care assignments for the unit. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is assisting in the care of a client who had a stroke and is having difficulty swallowing. The nurse should recommend a referral to which of the following members of the interprofessional team?

A nurse is assisting with the care of a client and asks the client. "Can you tell me about your day so far?" Which of the following therapeutic techniques is the nurse using?

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)