0900: Assessment completed, and the client was in bed alert and oriented to person, place, time, and situation. Clear lung fields bilaterally, with an infrequent dry cough. Heart tones S1 and S2. Peripheral pulses palpable and 2+. Skin was warm and dry. Bowel sounds were normoactive and present in all four quadrants. Incision was pink, approximated with staples, with scant serous drainage. Pain rated 4/10 on the Numerical Pain Rating Scale. Client refused to ambulate to the bedside chair for breakfast.
1159: Client informed nurse of their refusal to participate in physical therapy. Once up with PT, the client reported intense pain. The client reports that they have intense 'heaviness' in their left calf and that she needs a 'water pill' because it is swollen. The client was placed back in bed. She reports dyspnea immediately after failed ambulation attempt.
0900
Blood pressure 139/88 mm Hg
Heart rate 77/min
Respiratory rate 21/min
Temperature 99°F (37.2°C)
Pulse oximetry 92% on room air
1200
Blood pressure 149/91 mm Hg
Heart rate 87/min
Respiratory rate 24/min
Temperature 99°F (37.2°C)
Pulse oximetry 90% on room air
- hyperlipidemia
- generalized anxiety disorder
- irritable bowel syndrome
- chronic obstructive pulmonary disease
- diabetes mellitus (type two)
- osteoarthritis
➢ Complete the sentence below by choosing from the lists of options.
The nurse should recognize that the client may be experiencing [wound infection / hypoxia / venous thromboembolism / wound dehiscence] based on the client's [left lower extremity complaint. / vital signs. / pain at the surgical incision site. / wound assessment.]
Sign in to reveal the correct answer & rationale
A free account unlocks answers for the preview questions in every exam. A pass unlocks all of them.