An 86 year old woman had an anterior and posterior colporrhaphy (A & P repair) several days ago. Her retention catheter was removed 8 hours ago. Which assessment finding requires that you act most rapidly?

a. The oral temperature is 100.7 F (38.2 C)
b. The abdomen is firm and tender to palpation above the symphysis pubis.
c. Breath sounds are decreased, with fine crackles audible at both bases
d. The apical pulse is 86 beats/min and slightly irregular


Answer: b. The abdomen is firm and tender to palpation above the symphysis pubis.

Nursing

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The APRN is assessing the tympanic membrane of a patient. Once the tympanic membrane has been visualized, the APRN uses the bulb insufflator to observe the movement of the tympanic membrane

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