99. A nurse is caring for a 32-year-old client who is 1 day post–gastric bypass. Vital signs are: T 37.9°C, P 100, R 18, BP 130/80 mm Hg, pain 2/10, O2 Sat 92% on room air. The nurse should first:
99. A nurse is caring for a 32-year-old client who is 1 day post–gastric bypass. Vital signs are: T 37.9°C, P 100, R 18, BP 130/80 mm Hg, pain 2/10, O2 Sat 92% on room air. The nurse should first:
. Notify the physician for antibiotic orders.
. Have the client use the incentive spirometer.
. Increase intravenous fluids.
. Administer pain medication.
Test-Taking Tip
Look for the abnormal findings. The first action to take with a lower than normal O2 saturation is deep breathing and coughing.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is incorrect because any infection growing from surgery would not be showing up on postoperative day 1. This fever is from atelectasis. Answer 2 is correct because low-grade fever on postoperative day 1 is almost always an indication of atelectasis. This low O2 saturation supports this. Have the client take deep breaths on the incentive spirometer to open up the alveoli. Answer 3 is incorrect because the fever and low O2 Sat are most likely from atelectasis, not dehydration. Dehydration might be reflected in the rapid heart rate, but it would be accompanied by a lower BP. Answer 4 is incorrect because, when the pain level is 2/10, medications are not indicated.