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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "My advance directives will list what treatments I want if I'm unable to communicate.": Advance directives allow individuals to specify their healthcare preferences in situations where they are incapacitated. This includes decisions about life-sustaining treatments, resuscitation, and other medical interventions.
B. "My advance directives must be signed by my adult child in the presence of a judge.": Advance directives usually require the client’s signature and the signatures of two adult witnesses or notarization, depending on state laws. A judge’s involvement is typically not required.
C. "My family will be informed about my funeral choices in my advance directives.": Funeral or postmortem arrangements are not addressed in advance directives. These documents strictly relate to medical care preferences and decision-making in the event the client becomes unable to speak for themselves.
D. “I can indicate the organs will donate in my advance directives.": While some advance directive forms may include a section about organ donation, formal organ donor registration is typically completed through a driver’s license, organ donor card, or state registry—not as the main purpose of an advance directive.
Correct Answer is A
Explanation
Rationale:
A. Search for the medication on the National Library of Medicine's MedlinePlus website: This action allows the nurse to independently access a reliable, evidence-based source to gather essential information about the medication, including its purpose, dosage, side effects, and precautions. It promotes safe and informed medication administration.
B. Ask the charge nurse to explain the purpose of the medication: While consulting experienced colleagues is acceptable, relying solely on another person without verifying the medication through a formal, credible source may lead to misinformation. Independent verification is a safer and more accountable approach.
C. Ask the client to state the indication for the medication: Clients may not always have accurate knowledge of their medications or may misunderstand the reason for their use. Relying on client input does not ensure medication safety and is not a substitute for clinical validation.
D. Allow the client to self-administer the prepared medication: Allowing a client to self-administer a medication that the nurse does not understand is unsafe and violates standards of medication administration. Nurses are responsible for knowing what they administer and ensuring it is appropriate for the client's condition.
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