- 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 B
Explanation
Rationale:
A. Removal of the nasogastric tube is a more complex task that typically requires the nurse’s assessment and judgment.
B. Monitoring vital signs is within the scope of tasks that can be assigned to assistive personnel. This task involves routine observation and does not require complex decision-making.
C. Application of antibiotic ointment requires specific knowledge about the condition and treatment, which is generally performed by a nurse.
D. Obtaining medical history information is a task that requires clinical judgment and interaction, and should be done by a nurse rather than an assistive personnel.
Correct Answer is D
Explanation
Rationale:
A. Maintaining a client tracking system is crucial for managing large numbers of clients during a disaster.
B. Performing concise client assessment is essential for determining the severity of each client’s condition and prioritizing care.
C. Preventing cross-contamination of clients is important to prevent the spread of toxic substances.
D. Transferring a client to the discharge location is the lowest priority during a disaster, as immediate care and management of acute conditions take precedence over discharge planning.