After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first?
a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating
b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery
c. Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery
d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration
ANS: A
The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and/or possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient cough and deep breathe. Oral medications typically take more than 15 minutes for effective pain relief.
You might also like to view...
The nurse knows that basic suicide precautions may be started without a physician's order and maximum suicide precautions (or restrictions):
1. Need a physician's order and a psychiatric consult. 2. May be started on the recommendation of the psychiatric nurse. 3. Can be instituted without a physician's order only under emergency conditions. 4. Cannot be instituted without the client's consent.
The nurse is caring for a patient who is experiencing stress incontinence. Which goal is the most important for this patient?
a. The patient will carefully complete a voiding diary for the duration of 2 weeks. b. The patient will not experience involuntary urination during coughing or sneezing. c. The patient will be able to recognize and effectively manage perineal dermatitis. d. The patient will demonstrate how to appropriately use urinary incontinence products.
A client with prostate cancer is being discharged from the hospital. Which educational topic is inappropriate for this client?
A) Provide information on doses of complementary herbs. B) Teach the client and his family noninvasive methods of pain control. C) Stress the importance of keeping client appointments with healthcare providers. D) Provide the client and the client's family information on support groups.
A patient has been prescribed sildenafil. What should the nurse teach the patient about this medication?
A) Sexual stimulation is not needed to obtain an erection. B) The drug should be taken 1 hour prior to intercourse. C) Facial flushing or headache should be reported to the physician immediately. D) The drug has the potential to cause permanent visual changes.