The nurse cares for a patient who is one day post-op surgery. The nurse checks the patient's oral temperature and notes that it is 38° Celsius. Which action by the nurse is appropriate? Select all that apply.

Document the oral temperature in the health care record

Offer a blanket to prevent patient shivering

Inspect the surgical incision for redness, swelling, heat, & pain

Administer acetaminophen as ordered pm to reduce fever

Notify the Health Care Provider (HCP)

Answer and Explanation

Correct Answer : A,C,D,E

A. Document the oral temperature in the health care record: Accurate documentation of vital signs is a legal and clinical necessity for tracking the patient's postoperative trajectory. A temperature of 38°C represents a low-grade pyrexia that must be recorded to establish a trend. This data is essential for subsequent clinical decision-making and interdisciplinary communication.

B. Offer a blanket to prevent patient shivering: While blankets provide comfort, they can further insulate a febrile patient and cause a paradoxical rise in core body temperature. Shivering is a physiological mechanism to generate heat, but external warming during a fever is generally contraindicated unless the patient is in the chill phase. Nursing interventions should focus on heat dissipation.

C. Inspect the surgical incision for redness, swelling, heat, & pain: Assessment of the operative site is critical to differentiate between physiological postoperative inflammation and early surgical site infection. The nurse must evaluate for localized rubor, tumor, calor, and dolor as part of a comprehensive febrile workup. This helps identify the potential source of the elevated temperature.

D. Administer acetaminophen as ordered pm to reduce fever: Acetaminophen acts on the hypothalamic heat-regulating center to reduce fever and provide postoperative analgesia. Administration is appropriate when the temperature meets the threshold defined in the standing PRN orders. This intervention improves patient comfort and reduces the metabolic demands associated with pyrexia.

E. Notify the Health Care Provider (HCP): While low-grade fevers are common within 24 hours of surgery due to atelectasis or inflammatory stress, the HCP must be informed of any deviations from baseline. This ensures that the surgical team can order diagnostic tests, such as a chest X-ray or urinalysis, if indicated. Timely notification is a key component of postoperative surveillance.

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Correct Answer is C

Explanation

A. White flakes that are easily removed from hair shaft: This description is characteristic of seborrheic dermatitis or dandruff rather than Pediculosis humanus capitis. Lice nits are firmly cemented to the hair shaft by a chitinous substance and cannot be flicked or blown away. Ease of removal is a primary clinical differentiator from an active infestation.

B. Patchy bald spots over the scalp: Alopecia areata or tinea capitis typically cause localized hair loss and circular bald patches. While scratching from lice can cause secondary excoriation, it does not typically result in discrete areas of hair loss. Bald spots suggest a fungal infection or an autoimmune process rather than parasites.

C. Light brown colored dots attached to hair at nape of neck: These represent nits, which are the eggs of head lice, frequently found in warm areas like the nape of the neck or behind ears. Their firm attachment to the hair shaft and proximity to the scalp are definitive diagnostic markers. Identifying these is the standard for confirming a lice infestation.

D. Thick yellow crusts on the scalp: This finding is most often associated with "cradle cap" or severe seborrheic dermatitis, which involves an overproduction of sebum. It is an inflammatory skin condition rather than a parasitic infestation. While it may cause itching, it lacks the specific presence of nits or live lice.

A. Restrict fluid intake at night B. Ensure easy access to the toilet C. Eat raw fruits and vegetables D. Increase physical activity

Correct Answer is ["B","C","D"]

Explanation

A. Restrict fluid intake at night: Limiting fluids can lead to systemic dehydration and the formation of hard, dry stools that are difficult to evacuate. While it might reduce nocturia, it counteracts the goal of softening fecal matter for easier passage. Adequate hydration is essential for maintaining regular bowel motility in the elderly.

B. Ensure easy access to the toilet: Functional mobility issues often lead to the suppression of the urge to defecate, contributing to chronic constipation. Providing a clear path or bedside commode encourages the patient to respond promptly to physiological signals. This behavioral intervention supports the maintenance of a regular and healthy elimination schedule.

C. Eat raw fruits and vegetables: These food groups are high in insoluble fiber, which adds bulk to the stool and stimulates peristalsis. Fiber increases the speed of colonic transit and prevents the excessive absorption of water by the colon. Increasing dietary roughage is a primary non-pharmacological treatment for managing geriatric constipation.

D. Increase physical activity: Regular movement stimulates the smooth muscles of the gastrointestinal tract, promoting the forward movement of intestinal contents. Sedentary behavior is a major contributing factor to bowel stasis in the aging population. Walking or light exercise helps maintain the mechanical efficiency of the digestive system.

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The nurse cares for a patient who is one day post-op surgery. The nurse checks the patient's oral temperature and notes that it is 38° Celsius. Which action by the nurse is appropriate? Select all that apply.

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