ATI PN Adult Medical Surgical 2020 with NGN
ATI PN Adult Medical Surgical 2020 with NGN ( 79 Questions)
This finding does not need to be reported because it is within the normal range of temperature for adults (36.5° C to 37.5° C or 97.7° F to 99.5° F). A mild elevation in temperature may occur after surgery due to inflammation or dehydration and does not indicate infection unless it exceeds 38° C (100.4° F).
This finding does not need to be reported because it is expected after abdominal surgery due to anesthesia, pain medication, or decreased mobility that can slow down bowel motility. Hypoactive bowel sounds are defined as less than five sounds per minute. The nurse should encourage the client to ambulate, drink fluids, and eat high-fiber foods to stimulate bowel function.
This finding needs to be reported because it indicates a possible infection at the surgical site. Red streaks along the incision are a sign of cellulitis, which is a bacterial infection of the skin and underlying tissue that can spread rapidly and cause serious complications. The nurse should also check for other signs of infection such as warmth, swelling, pain, pus, or foul odor at the incision site.
This finding does not need to be reported because it is normal during the first few days after surgery. Serosanguineous drainage is a mixture of blood and clear fluid that leaks from the wound as part of the healing process. The nurse should monitor the amount, color, and consistency of the drainage and change the dressing as needed.
Choice A reason: This finding does not need to be reported because it is within the normal range of temperature for adults (36.5° C to 37.5° C or 97.7° F to 99.5° F). A mild elevation in temperature may occur after surgery due to inflammation or dehydration and does not indicate infection unless it exceeds 38° C (100.4° F).
Choice B reason: This finding does not need to be reported because it is expected after abdominal surgery due to anesthesia, pain medication, or decreased mobility that can slow down bowel motility. Hypoactive bowel sounds are defined as less than five sounds per minute. The nurse should encourage the client to ambulate, drink fluids, and eat high-fiber foods to stimulate bowel function.
Choice C reason: This finding needs to be reported because it indicates a possible infection at the surgical site. Red streaks along the incision are a sign of cellulitis, which is a bacterial infection of the skin and underlying tissue that can spread rapidly and cause serious complications. The nurse should also check for other signs of infection such as warmth, swelling, pain, pus, or foul odor at the incision site.
Choice D reason: This finding does not need to be reported because it is normal during the first few days after surgery. Serosanguineous drainage is a mixture of blood and clear fluid that leaks from the wound as part of the healing process. The nurse should monitor the amount, color, and consistency of the drainage and change the dressing as needed.