Which of these assessments of a patient who is 1 day post surgery to repair a hip fracture requires immediate nursing intervention?
a. Patient ate 30% of clear liquid breakfast.
b. Oral temperature is 99.2° Fahrenheit.
c. Patient states, "Boy, I did not realize I would be so tired after this surgery."
d. Patient reports severe pain 30 minutes after receiving pain medication.
ANS: D
The nurse needs to recognize and differentiate normal from abnormal findings and set priorities. The nurse needs to report severe pain that is unrelieved by pain medication to the health care provider. Eating 30% of breakfast, having a slightly elevated temperature, and being tired the day after surgery are expected findings following surgery and do not require immediate intervention.
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