The client's tympanic temperature is 101° F 36 hours postoperatively. Which intervention(s) does nurse implement for the client? (Select all that apply.)

Question

1. Obtain a wound culture.
2. Position in semi-Fowler's.
3. Encourage intake of fluids.
4. Notify provider of infection.
5. Promote breathing exercises.
6. Check white blood cell count.

Answer 1

2, 3, 5, 6
2. Semi-Fowler's position facilitates lung expansion and is a suitable nursing intervention to open areas of atelectasis and to prevent pneumonia.
3. The client is febrile 36 hours after surgery; however, this finding alone does not indicate that the client has an infection because dehydration and hypoventilation cause many postoperative fevers. The fever warrants further investigation by the nurse, but the nurse initiates care by encouraging oral fluids to rehydrate the client.
5. Because many postoperative fevers are present with atelectasis, the nurse auscultates the client's lungs and encourages coughing, deep breathing, and using the incentive spirometer to open collapsed alveoli.
6. The nurse checks the white blood cell count for leukocytosis, indicative of infection and inflammation.
1. The nurse avoids obtaining a wound culture for now because the only indicator of infection is the fever. If the fever persists despite nursing interventions, the nurse collaborates with the provider to obtain a culture.
4. Notifying the provider of an infection is premature; the nurse needs additional objective data, including a positive culture, to conclude an infection is present.