A patient, recovering from a kidney transplant, has a temperature of 38 degrees C. Which of the following should the nurse do?
1. Report the temperature so a thorough assessment of the source can be discovered and treated.
2. Document the temperature and begin trending over the next 24 hours.
3. Provide antipyretic medication as prescribed.
4. Increase fluids and encourage ambulation.
1
Rationale: Infection is a major post-transplantation problem because immunosuppressant therapy compromises the immune system in some way. The primary symptom of infection in the transplant population is the presence of a fever of about 100.5°F or 38 degrees C. Development of a fever requires a rapid but thorough search for the source of the infection and aggressive treatment. Even though the lungs and urinary tract are the most common sources of nosocomial infection, this has yet to be determined for the patient therefore increasing fluids and encouraging ambulation may or may not be indicated for the patient. The nurse needs to do more than document and trend the temperature readings. The nurse also needs to do more than provide antipyretic medication.
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