- 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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Correct Answer is D
Explanation
Rationale:
A. Measuring I&O is a task typically assigned to APs or RNs, not specifically requiring the LPN’s scope of practice.
B. Obtaining a client’s weight is a basic task that can be performed by APs.
C. Providing postmortem care can be performed by LPNs, but this task is not as complex as some others.
D. Inserting a nasogastric tube requires skills and knowledge specific to LPNs, making it an appropriate task for them.
Correct Answer is D
Explanation
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.