58. Following colostomy-reversal surgery, a client refuses to wear the prescribed antiembolic stockings. A prophylactic heparin dose was not given because the order was unclear. Admission BP was 130/80 mm Hg; pulse 106. Morphine was given for pain. The next morning the BP is 88/60 mm Hg and the pulse is 140. Pain level is 5/10. The correct action by a nurse would be:
. Check pulse oximetry and breath sounds.
. Give morphine as prescribed for pain.
. Check for a positive Homans' sign.
. Notify the physician of the BP changes.
Test-Taking Tip
In 24 hours ("the next morning") the risk is pulmonary emboli, not thrombophlebitis. Therefore, do additional respiratory assessments, not assessments for inflammation ("-itis").
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Vital Signs Changes/Abnormalities
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Answer 1 is correct because this client is at high risk for pulmonary emboli. Assess for additional signs before calling the physician. Answer 2 is incorrect because the pain is not severe enough to cause the vital sign changes. Note that morphine was given; additional morphine is not indicated. Answer 3 is incorrect because the risk is pulmonary emboli, not thrombophlebitis. Answer 4 is incorrect because the physician will need additional data that the nurse needs to provide first.