The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
a. Blood glucose 136 mg/dL
b. Oral temperature 101° F (38.3° C)
c. Patient complaint of increased incisional pain
d. Separation of the proximal wound edges by 1 cm
ANS: D
Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly.
You might also like to view...
The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?
A) Anxiety related to diagnosis of cancer B) Altered nutrition related to swallowing difficulties C) Ineffective airway clearance related to airway alterations D) Impaired verbal communication related to removal of the larynx
A care aide who works in a long-term care facility recognizes the high incidence and prevalence of a stage I pressure ulcer in immobile older adults
Which of the following protocols in the facility would the care aide advocate changing? A) Residents with persistently low food intake are identified. B) Immobilized residents are turned every 2 hours during both day and night. C) Residents are frequently encouraged to increase their fluid intake. D) Wound dressings are applied promptly to all identified or potential pressure ulcers.
Which characteristics should the oncology nurse expect when assessing a patient recently diagnosed with indolent non-Hodgkin lymphoma (NHL)?
A) No discernible symptoms B) Painful lymphadenopathy C) Night sweats and unexplained fever D) Anemia and fatigue
One or 2 days after a myocardial infarction, patients are likely to best tolerate
a. a clear liquid diet. b. mostly cold foods. c. small, frequent meals. d. three moderate meals a day.