The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.)

Question

a. Patient with abdominal surgery has patent airway.
b. Patient with knee surgery has approximated incision.
c. Patient with femoral artery surgery has strong pedal pulse.
d. Patient with lung surgery has 20 mL/hr of urine output via catheter.
e. Patient with bladder surgery has bloody urine within the first 12 hours.
f. Patient with appendix surgery has thready pulse and blood pressure is 90/60.

Answer 1

ANS: D, F
Thready pulse, low blood pressure, and urine output of 20 mL/hr need to have follow-up by the nurse. Hemorrhage results in a fall in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. Notify the surgeon if these changes occur. If the patient has a urinary catheter, there should be a continuous flow of urine of approximately 30 to 50 mL/hr in adults; this patient requires follow-up since the output is 20 mL/hr. All the rest are normal findings. A patent airway, a strong distal pulse, and approximated incision are all normal findings. Surgery involving portions of the urinary tract normally causes bloody urine for at least 12 to 24 hours, depending on the type of surgery.