medium · NCLEX-RN Safety and Infection Prevention and Control
The nurse is assessing a client on the oncology unit who is 10 days post-chemotherapy. The client reports a new onset of 'feeling chilly' but has a temperature of 37.6°C (99.7circF) and no visible redness or purulence at the central venous access site.
Which principle should guide the nurse's next action?
- Muted inflammatory responses in neutropenia mean minor temperature elevations can signal systemic sepsis.
- The nurse should encourage oral fluids and reassess the temperature in four hours to establish a trend.
- A temperature below 38.0°C (100.4circF) in an oncology client is considered an expected finding during the chemotherapy nadir.
- The absence of redness and purulence at the catheter site confirms that the access device is not the source of infection.
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