When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first?
a. Have the patient use the incentive spirometer.
b. Assess the surgical incision for redness and swelling.
c. Administer the ordered PRN acetaminophen (Tylenol).
d. Ask the health care provider to prescribe a different antibiotic.
ANS: A
A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature.
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