The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?
a. The right calf is swollen, warm, and painful.
b. The patient's temperature is 100.3° F (37.9° C).
c. The 24-hour oral intake is 600 mL greater than the total output.
d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.
ANS: A
The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.
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