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. Severe immunodeficiency B. Asymptomatic HIV C. Mild febrile illness D. Egg allergy

Correct Answer is A

Explanation

Rationale:

A. Severe immunodeficiency: The MMR vaccine is a live attenuated vaccine and is contraindicated in clients with severe immunodeficiency, such as those undergoing chemotherapy or with advanced HIV/AIDS. These individuals cannot mount an appropriate immune response, placing them at risk for vaccine-related complications.

B. Asymptomatic HIV: Clients with asymptomatic HIV and adequate CD4 counts may safely receive the MMR vaccine. It is not contraindicated unless the client is significantly immunocompromised.

C. Mild febrile illness: Mild illnesses, such as low-grade fever or upper respiratory infections, do not contraindicate vaccine administration. The MMR vaccine can still be safely given, as minor illness does not significantly alter vaccine response or increase risks.

D. Egg allergy: Although the MMR vaccine is cultured in chick embryo fibroblasts, it does not contain significant egg protein, and studies have shown it can be safely administered to individuals with egg allergies. An egg allergy is not a valid reason to withhold the vaccine.

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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?

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