Question

A nurse is assessing a client post-op. Which of the following complaints should the nurse report immediately? a) Mild incisional pain b) Swelling at the surgical site c) Temperature of 100.2°F (37.9°C) d) Increased confusion and restlessness

Answer 1

d) Increased confusion and restlessness

The nurse should report the complaint of increased confusion and restlessness immediately. These symptoms may indicate a potential complication, such as cerebral hypoxia or infection. It is important to promptly evaluate and address any changes in mental status post-operatively to ensure the client's safety and well-being.

While the other complaints of mild incisional pain, swelling at the surgical site, and a temperature of 100.2°F (37.9°C) should not be ignored, they may not require immediate reporting unless they are severe or accompanied by other concerning symptoms. The nurse should continue to assess and monitor these symptoms, provide appropriate interventions and document any changes in the client's condition.