The nurse notes the client's tympanic temperature is 100.2° F at 4 PM on the client's second postoperative day. Which does the nurse implement?
1. Checks leukocyte count
2. Collaborates for cultures
3. Asks client to drink fluid
4. Offers client more blankets
3
3. The nurse asks the client to drink more fluid and to cough and deep breathe be-cause low-grade temperatures frequently indicate dehydration and atelectasis in postoperative clients; in addition, client temperatures generally peak at 6 PM . The nurse evaluates the client's temperature again in 2 hours and expects to obtain a lower temperature. If not, the nurse assesses the client for infection and collaborates with the provider to plan care.
1. After instructing the client to drink fluids and to cough and deep breathe, the nurse can check the leukocyte count to provide important assessment.
2. Until the nurse tries fluid and verifies the temperature, collaborating for specimen cultures is premature; besides, the provider potentially will not want to culture for a low-grade temperature.
4. Additional blankets are contraindicated unless the client is shivering.
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