Nokea
The patient develops a low-grade fever 18 hours post-operatively and has diminished breath sounds. Which of the following actions is most appropriate for the nurse to take to prevent complications? i.Administer antibiotics iv.Decrease fluid intake ii.Encourage coughing and deepbreathing v.Ambulate patient as ordered iii.Administer acetaminophen (Tylenol)
Correct Answer: A
Rationale: In this scenario, the patient developing a low-grade fever post-operatively along with diminished breath sounds could indicate the possibility of atelectasis or pneumonia. The most appropriate actions for the nurse to take to prevent complications in this situation would be to encourage coughing and deep breathing (to help clear secretions and improve lung expansion) and ambulate the patient as ordered (to promote lung ventilation and prevent further complications). Administering antibiotics, acetaminophen for fever management, and decreasing fluid intake may be considered based on the healthcare provider's assessment and orders, but the immediate nursing interventions to address the presenting symptoms are encouraging coughing and deep breathing and ambulating the patient.