The nurse assesses the client who has a surgical incision. Which is an expected client outcome on the fourth postoperative day?
1. Tympanic temperature is 38.5° C at 8 AM and 12 noon
2. Slightly reddened and swollen incision, without drainage
3. Hyperactive bowel sounds in all quadrants with guarding
4. Client ambulates to the bathroom with minor assistance
2
2. On the fourth postoperative day, the client's surgical incision is expected to have slight redness and swelling but no drainage, indicating a physiological, expected, inflammatory response to tissue injury. Incisional drainage is an unexpected finding because, if fluid is able to leak out, microorganisms are able to enter the wound. If an incision does begin to leak, monitor the client very closely for early detection of a wound infection. The healing ridge is apparent at the fifth postoperative day.
1. The client is febrile and the temperature warrants further investigation to rule out infection.
3. Bowel sounds usually return by the fourth postoperative day but are not hyperactive because hyperactivity equates to intestinal hypermotility; guarding is a protective reflex indicative of pain and discomfort. The client's presentation warrants further investigation.
4. On the fourth postoperative day, the client should ambulate to the bathroom without assis-tance.
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