Fever and other vital sign changes of infection
Question
Click to highlight the findings that require follow-up.
Client is a 78-year-old on postoperative day 3 after bowel surgery. Oral temperature is 101.5 F (38.6 C). Heart rate is 112 and respiratory rate is 24. The client was oriented yesterday but is newly confused and asking where they are. The abdominal incision has yellow-green drainage on the dressing. The client ate 75 percent of lunch. The bed is in the low position with the call light within reach. The client denies pain at rest.
Highlighted phrases are the correct selections.
Answer
Oral temperature is 101.5 F (38.6 C). · Heart rate is 112 and respiratory rate is 24. · The client was oriented yesterday but is newly confused and asking where they are. · The abdominal incision has yellow-green drainage on the dressing.
Rationale
A temperature of 100.4 F (38 C) or higher is a fever, and infection raises the metabolic rate, which increases the heart rate and may increase the respiratory rate. New confusion and purulent (yellow or green) drainage from a wound are unexpected findings that suggest infection and should be reported. Older adults may not have much of a fever and can show new confusion instead, so the change in mental status deserves particular attention. A good appetite, a safe bed position, and no pain at rest are not concerns here.
Sources
Sources marked “Adapted from” are licensed under CC BY 4.0. We changed the material: its facts are rewritten into an original question, answer options and rationale. The original authors and publishers do not endorse SwipeExam.
- Adapted from Open RN Nursing Assistant: Chapter 4: Adhere to Principles of Infection Control
- Adapted from Open RN Medical Terminology, 2nd edition: Chapter 11 Lymphatic & Immune Systems Terminology
- Adapted from Open RN Health Alterations: Chapter 3 Hematological Alterations
- Adapted from Open RN Nursing Pharmacology, 2nd edition: Chapter 3 Antimicrobials
- Sepsis (MedlinePlus health topic)
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