The nurse caring for a postsurgical patient obtains an oral temperature reading of 102°F (38.9°C). The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? Select all that apply.

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The nurse should document the patient's oral temperature of 102°F (38.9°C) as it is the vital sign that prompted intervention. Documenting communication with the surgeon about obtaining an order is essential for legal and clinical communication purposes. Finally, documenting the administration of acetaminophen 650 mg orally is crucial for medication management and continuity of care. The incorrect administration of aspirin (D) was not mentioned in the scenario, and the rectal temperature (E) was not taken, making A, B, and C the correct choices to document.

The Nurse Caring for a Postsurgical Patient Obtains an Oral