NursingPlex
    Sign In
    PN Comprehensive Predictor 2023 Proctored Exam

    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?

    Explanation & Rationale

    A. Assist the client with dangling off the side of the bed: While mobilization can help prevent complications such as atelectasis or thromboembolism, it does not address the immediate concern of a possible postoperative infection indicated by the elevated temperature. B. Obtain a prescription to check the client's CBC: Ordering a CBC can help identify infection or inflammation, but it is a diagnostic action that follows initial assessment. Immediate assessment of potential sources of infection takes priority. C. Check the condition of the client's surgical incision: Assessing the surgical site is the first action because an incision can be a primary source of infection in postoperative clients. Early identification of redness, drainage, or other signs of infection allows prompt intervention. D. Instruct the client to breathe deeply and cough: Deep breathing and coughing are important for preventing respiratory complications, but they do not address the urgent need to assess for infection, which is indicated by the elevated temperature.

    🔒 Submit your answer to reveal