The nurse has just reassessed the condition of the postoperative client who was admitted 1 hour ago to the surgical unit. The nurse monitors which of the following parameters during the next hour most carefully?
1. Urinary output of 20 mL/hr
2. Temperature of 37.6° C (99.6° F)
3. Blood pressure of 116/78 mm Hg
4. Serous drainage on the surgical dressing
1
Rationale: Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL/hr for each of two consecutive hours should be reported to the physician. A temperature above 37.7° C (100° F) or below 36.1° C (97° F) and a falling systolic blood pres-sure, under 90 mm Hg, are usually considered reportable at once. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
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The nurse administered morphine intravenously to a four-year-old postoperative patient. Thirty minutes later, the nurse assesses the child. Which assessment finding requires further evaluation?
1. Pulse decreased from 136 to 104 2. Blood pressure dropped from 110/72 to 90/55 3. Respiratory rate went from 42 to 16 4. Child pulls away from nurse who wants to assess surgical site
A nurse is performing an admission assessment on a middle-age patient. A normal change seen in this age group includes which of the following? (Select all that apply.)
a. A progressive decrease in skin turgor b. Decreased visual acuity c. Decreased ability to solve practical prob-lems d. Decreased strength of abdominal muscles e. Loss of accommodation
A woman presents to the emergency department after working outdoors in the sun all day. The nurse suspects heat exhaustion after his initial interview and assessment of the client. Which of the following symptoms would support his diagnosis?
A. Confusion B. Normal body temperature C. Elevated body temperature D. Hypertension
The nurse notes a significant change in the client's condition. The nurse should
a. notify the physician and document the change and the notification of the physician in the chart b. document the change in the chart c. notify the physician and chart that the physician was notified d. chart the change and notify the nursing supervisor