A nurse is caring for a postoperative client who has developed peritonitis. An assessment finding that would require immediate action would be
a. a decrease in blood pressure of more than 15 mm Hg.
b. an increase in urine output of more than 300 ml/day.
c. pulse deficit of more than 20 beats/minute.
d. weight gain of more than 5 pounds.
A
Postoperatively, the nurse should closely monitor the client for development of postoperative complications (e.g., adult respiratory distress syndrome [ARDS], sepsis, shock) by changes in vital signs, immediately reporting any manifestations of sepsis (e.g., decrease/increase in tem-perature, decrease in blood pressure). A urine output of only 300 ml in 1 day is below normal for an adult (30-50 ml/hr). Pulse deficit and weight gain would not indicate a common postoperative complication.
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