Which assessment of a patient who is 1 day postsurgery to repair a hip fracture requires immediate nursing intervention?
a. Patient ate 40% of clear liquid breakfast.
b. Patient's oral temperature is 98.9° F.
c. Patient states, "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
It is important to prioritize in all caregiving situations because it allows you to see relationships among patient problems and avoid delays in taking action that possibly leads to serious complications for a patient. The nurse needs to report severe pain that is unrelieved by pain medication to the health care provider. The nurse needs to recognize and differentiate normal from abnormal findings and set priorities. Eating 40% 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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