The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?
1. Encourage oral fluids to prevent dehydration
2. Recheck temperature 15 minutes after removing hot liquids from the bedside
3. Ask the client to drink only cold water and juices
4. Chart this temperature elevation on the flow sheet
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Answer
The correct answer is number: 2
Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading. Avoid premature assumptions about explanations for findings. The other options are incorrect.
Smeltzer, S.C., & Bare, B.G.(2004).
Medical surgical nursing (10th ed.).
Philadelphia: Lippincott Williams & Wilkins
Altman, G.
Delmar’s fundamental and advanced nursing skills (2nd ed.)
Albany, NY: Delmar.
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