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  1. 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

A.

Medication for elevated temperature

B.

Insertion of NG tube for decompression

C.

Oxygen 2 to 4 L/min via nasal cannula

D.

Insertion of urinary catheter

E.

Evaluation of surgical wound drain

Question Solution

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.


View Related questions

Correct Answer is D

Explanation

Rationale:

A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.

B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.

C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.

Correct Answer is B

Explanation

Rationale:

A. "The client works in the hospital radiology department." This information is important for understanding the client's background but does not indicate a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide." This statement indicates a high-risk situation requiring close monitoring and direct care by the nurse, rather than delegating tasks to an AP. The client's safety and mental health status necessitate the nurse's full attention.

C. "The client's blood pressure and pulse have been fluctuating throughout the day." While this information suggests the need for monitoring, it doesn't necessarily preclude the AP from assisting with certain tasks under the nurse's supervision.

D. "The client's family members have been present most of the day." This statement provides context but does not indicate a need for total care by the nurse.