- A nurse is caring for a client who is postoperative.
Nurses' Notes
1400:
Client transferred from PACU following appendectomy. Oriented to person, place, and time. Surgical dressing is dry and intact. Wound drain has 30 mL of serosanguinous drainage. Client reports pain is 7 on a scale of 0 to 10.
2200
Bowel sounds are present in all quadrants. Client is passing flatus. Urinary output is 400 mL over 6 hr. Client reports incisional pain of 4 on a scale of 0 to 10. Surgical dressing has a moderate amount of serosanguinous drainage. Wound drain has 0 mL output over 8 hr.
Vital Signs
1400:
Temperature 37.8° C (100" F)
Heart rate 110/min
Respiratory rate 18/min
Blood pressure 165/70 mmHg
SpO2 95% on room air
1800:
Temperature 37.8° C (100° F)
Heart rate 96/min
Respiratory rate 20/min
Blood pressure 125/78 mmHg
SpO2 96% on room air
Provider Prescriptions
1400
Ceftriaxone 1 gram IV daily
Acetaminophen 650 mg PO every 6 hours for pain
Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply
Medication for elevated temperature
Insertion of NG tube for decompression
Oxygen 2 to 4 L/min via nasal cannula
Insertion of urinary catheter
Evaluation of surgical wound drain
Correct Answer : A,E
Rationale:
A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.
B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.
C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.
D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.
E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.
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View Related questions
Correct Answer is ["B","E","F","I"]
Explanation
Rationale:
A. Typically involved in helping clients with activities of daily living due to physical or cognitive impairments, which is not the primary focus in this scenario.
B. May be involved if there is a need for possible surgical management due to complications or disease progression. Surgical intervention can be necessary for Crohn's disease, particularly if there are abscesses, strictures, or fistulas.
C. While important in general rehabilitation, physical therapy is not specifically indicated in this case unless there are complications affecting physical mobility.
D. While they perform diagnostic imaging, they are not directly involved in the ongoing care plan or treatment decisions.
E. Essential for managing nutritional needs, especially given the client's weight loss and inability to keep food down. A dietitian can help develop a plan to address nutritional deficiencies and manage symptoms through diet.
F. A specialist in gastrointestinal diseases who will likely be a key member of the team for managing and evaluating the client's Crohn's disease, overseeing medical and therapeutic interventions.
G. Generally involved if there are issues with swallowing or speech, which is not indicated here.
H. Though crucial in medication management, their role is more supportive in reviewing medication plans rather than direct patient care involvement in this specific scenario.
I. Important for addressing psychosocial issues, such as the client's frustration and possible depression. They can assist with coping strategies, support services, and facilitating access to community resources.
Correct Answer is D
Explanation
Rationale:
A. "Use wool blankets on your bed" is not recommended as wool is a flammable material that can pose a risk with oxygen use.
B. "Store unused oxygen tanks horizontally" is not correct; tanks should be stored upright to prevent damage or leakage.
C. "Check your oxygen equipment once each week" is insufficient; equipment should be checked more frequently to ensure safety.
D. "Do not adjust the oxygen flow rate" is correct as clients should not make adjustments without medical advice to ensure proper oxygen levels are maintained.