The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

Validate the finding

Document the finding

Inform the surgeon

Inform the charge nurse

Answer and Explanation

The Correct Answer is A

A. Validate the finding:

Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.

B. Document the finding:

Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.

C. Inform the surgeon:

If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.

D. Inform the charge nurse:

Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.

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Correct Answer is A

Explanation

A. Carotid

The nurse should avoid assessing the carotid pulses bilaterally at the same time. The carotid arteries are major blood vessels supplying the head and neck with oxygenated blood. Simultaneously assessing both carotid pulses could potentially compromise blood flow to the brain, leading to a decrease in cerebral perfusion. This is particularly important in individuals with a history of cerebrovascular disease or other conditions affecting blood flow to the brain.

B. Brachial:

Assessing the brachial pulses bilaterally at the same time is generally acceptable. The brachial pulses are located in the upper arms.

C. Popliteal:

Assessing the popliteal pulses bilaterally at the same time is generally acceptable. The popliteal pulses are located behind the knee.

D. Femoral:

Assessing the femoral pulses bilaterally at the same time is generally acceptable. The femoral pulses are located in the groin area.

A. Pallor B. Jaundice C. Cyanosis D. Erythema

Correct Answer is C

Explanation

A. Pallor:

Pallor refers to an unusually pale or white skin color. It is often associated with reduced blood flow, anemia, or shock. Pallor is characterized by a lack of the normal rosy color of the skin.

B. Jaundice:

Jaundice is a yellowing of the skin and mucous membranes due to an excess of bilirubin in the blood. It can be associated with liver dysfunction or other conditions affecting the normal breakdown and elimination of bilirubin.

C. Cyanosis:

Cyanosis is a bluish-gray discoloration of the skin and mucous membranes caused by a decrease in oxygen levels in the blood. It can result from various conditions affecting oxygenation, such as respiratory or circulatory problems. In the context of a broken leg, cyanosis on the affected leg could suggest compromised blood flow or oxygenation.

D. Erythema:

Erythema refers to redness of the skin, often due to increased blood flow to the area. It can be a normal response to irritation, injury, or inflammation. Unlike bluish-gray discoloration seen in cyanosis, erythema is characterized by a red appearance.

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The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

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The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?