You are caring for a 68-year-old patient who underwent abdominal surgery 24 hours ago. The patient has a history of type 2 diabetes mellitus and hypertension. Post- operative orders include monitoring of vital signs every 4 hours, assessing the surgical site for signs of infection, pain management, and early mobilization. The patient is currently NPO (nothing by mouth) and has an IV infusion of 0.9% saline at 100 mL/hr. The patient's current vital signs are: blood pressure 160/90 mmHg, pulse 96 beats/min, respiratory rate 20 breaths/min, and temperature 37.8°C (100°F). The patient complains of moderate pain at the surgical site, rating it 6 out of 10 on the pain scale, and appears anxious about the pain and the potential for complications. Given this scenario, which of the following nursing actions should be prioritized? A) Administering the prescribed PRN (as needed) analgesic for pain management. B) Assessing the surgical site for signs of infection or complications. C) Encouraging the patient to perform deep breathing and leg exercises. D) Notifying the healthcare provider of the patient's elevated blood pressure and temperature.
You are caring for a 68-year-old patient who underwent abdominal surgery 24 hours ago. The patient has a history of type 2 diabetes mellitus and hypertension. Post- operative orders include monitoring of vital signs every 4 hours, assessing the surgical site for signs of infection, pain management, and early mobilization. The patient is currently NPO (nothing by mouth) and has an IV infusion of 0.9% saline at 100 mL/hr. The patient's current vital signs are: blood pressure 160/90 mmHg, pulse 96 beats/min, respiratory rate 20 breaths/min, and temperature 37.8°C (100°F). The patient complains of moderate pain at the surgical site, rating it 6 out of 10 on the pain scale, and appears anxious about the pain and the potential for complications. Given this scenario, which of the following nursing actions should be prioritized? A) Administering the prescribed PRN (as needed) analgesic for pain management. B) Assessing the surgical site for signs of infection or complications. C) Encouraging the patient to perform deep breathing and leg exercises. D) Notifying the healthcare provider of the patient's elevated blood pressure and temperature.
Chapter19: Child Health
Section: Chapter Questions
Problem K1CRE
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