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.

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Correct Answer is A

Explanation

Rationale:

A. Contact security personnel to place the money in the designated secure location: Hospitals have protocols for handling client valuables. The safest and most appropriate action is to notify security so the funds can be securely stored, documented, and returned appropriately. This maintains accountability and protects both the client and staff.

B. Label the money with the client's name and leave it at the nurses' station: Leaving valuables at the nurses' station, even if labeled, poses a risk for loss or theft. It does not meet institutional standards for safeguarding client property and may violate facility policies.

C. Place the money in an envelope in the client's medication drawer: Medication drawers are intended for storing prescribed medications only. Using them for valuables is inappropriate, insecure, and may lead to misplacement or confusion during care transitions.

D. Hold the money for the client until their return from surgery: Personally holding the client’s money is a liability and not an accepted protocol. It lacks formal documentation and security, increasing the risk of loss or accusation of theft.

A. Erythema toxicum B. Bacterial vaginosis C. Molluscum contagiosum D. Gonorrhea

Correct Answer is D

Explanation

Rationale:

A. Erythema toxicum: This is a common and benign rash seen in newborns. It is not infectious, poses no public health risk, and does not require mandatory reporting.

B. Bacterial vaginosis: Although it is a vaginal infection, bacterial vaginosis is not classified as a reportable condition. It does not pose the same level of public health concern as sexually transmitted infections like gonorrhea.

C. Molluscum contagiosum: Molluscum contagiosum is a viral skin infection that is generally self-limiting and not considered a reportable disease. It does not require public health intervention in most cases.

D. Gonorrhea: Gonorrhea is a nationally notifiable disease in many countries, including the United States, due to its infectious nature and potential for serious complications. Public health reporting is required to track, treat, and prevent its spread.

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