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.

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.