A nurse who works on the orthopedic unit has just received the change-of-shift report. Which patient should the nurse assess first?
a. Patient who reports foot pain after hammertoe surgery
b. Patient with low back pain and a positive straight-leg-raise test
c. Patient who has not voided 10 hours after having a laminectomy
d. Patient with osteomyelitis who has a temperature of 100.5° F (38.1° C)
ANS: C
Difficulty in voiding may indicate damage to the spinal nerves and should be assessed and reported to the surgeon immediately. The information about the other patients is consistent with their diagnoses. The nurse will need to assess them as quickly as possible, but the information about them does not indicate a need for immediate intervention.
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