A nurse is monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?

Atelectasis.

Dehydration.

Inflammation.

Infection.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Atelectasis is the collapse of alveoli in the lungs, which can impair gas exchange and cause hypoxia. It can occur after surgery due to anesthesia, pain, or immobility. However, atelectasis does not usually cause fever and chills, unless it is complicated by pneumonia.

Choice B reason:

Dehydration is the loss of fluid and electrolytes from the body, which can affect blood pressure, heart rate, and kidney function. It can occur after surgery due to blood loss, vomiting, or inadequate intake. However, dehydration does not usually cause fever and chills, unless it is associated with infection or heat stroke.

Choice C reason:

Inflammation is the body's response to tissue injury or infection, which involves increased blood flow, swelling, pain, and heat. It can occur after surgery as part of the normal healing process. However, inflammation does not usually cause fever and chills, unless it is severe or systemic.

Choice D reason:

Infection is the invasion and multiplication of microorganisms in the body, which can trigger an immune response and cause inflammation, fever, and chills. It can occur after surgery due to contamination of the surgical site, catheters, or intravenous lines. Infection is the most likely cause of fever and chills in a postoperative patient.

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

A. Administering oxygen may help improve oxygen saturation, but the primary concern is hypotension and tachycardia, which suggest possible hypovolemia.
B. The patient’s vital signs, BP 90/60 mmHg, pulse 120 beats/min, urine output 20 mL/h, indicate early hypovolemic shock. The priority intervention is to increase intravenous fluids to restore circulating volume and perfusion.
C. Notifying the physician is important but should follow initiating immediate interventions to stabilize the patient.
D. Administering pain medication does not address the patient’s hemodynamic instability and is not a priority at this time.

A. Notify the provider of the findings. B. Obtain a wound culture from the surgical site. C. Administer an antibiotic as ordered. D. Increase the frequency of perineal care.

Correct Answer is A

Explanation

Choice A reason:

The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.

Choice B reason:

Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.

Choice C reason:

Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.

Choice D reason:

Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.

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 monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is preparing a client for discharge after a mastectomy. The nurse teaches the client how to perform arm exercises to prevent lymphedema and promote mobility. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is changing the dressing of a patient who had a chest surgery two days ago. The nurse observes that the wound edges are separated and there is a small amount of pink serous drainage on the dressing. What should the nurse do?

A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)

A nurse is teaching a patient about wound care after a minor surgical procedure. Which of the following instructions should the nurse include? (Select all that apply.)

A nurse is monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?

A nurse is assessing a patient's pain level after surgery. The patient rates their pain as 8 out of 10 and says it feels like a sharp stabbing pain in the surgical site. What should the nurse say to the patient?

A nurse is assessing a client who had a thyroidectomy. The nurse suspects that the client is experiencing hypocalcemia due to inadvertent damage to the parathyroid glands. Which of the following statements by the client supports this suspicion?