The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body.After 3 days,the nurse notes that the patient's temperature is newly elevated at 100.2°F (37.9°C),and the patient exhibits new-onset agitation and confusion.What should the nurse do first?

Question

Quizplus · Accepted Answer

The nurse should continually assess for and report signs and symptoms of sepsis: temperature elevation,change in sensorium,changes in vital signs and bowel sounds,decreased output,and positive blood/wound cultures.A rise in temperature should be reported.A.C.D.Further monitoring,Tylenol,and fluids may also be appropriate but only after the HCP determines the cause of the change and provides recommendations.

The Nurse Is Caring for a Patient Admitted to the Burn