Question

A nurse is caring for a client who is postoperative following abdominal surgery.

Nurses' Notes
1100:Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach.
1115:Provider prescriptions reviewed.
1200:Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered.
1230:Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort.

Medication Administration Record
Morphine 4 mg IV bolus every 4 hr PRN pain
Metoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting

Vital Signs
1100:Temperature 36.2° C (97.2° F)
Heart rate 76/min
Respirations 18/minBP 122/68 mm Hg
Oxygen saturation 95% on room air
1200:Temperature 36.8° C (98.2° F)
Heart rate 116/min
Respirations 20/minBP 112/68 mm Hg
Oxygen saturation 93% on room air

Which should the nurse report to the provider?
A. Neurological assessment
B. Incisional drainage
C. Urinary output
D. Reported pain level
E. Gastrointestinal assessment
F. Vital signs

Answer 1

The nurse should report the low urinary output, the increased pain levels despite medication, and the concerning changes in vital signs to the provider.

Step-by-step explanation:

The nurse should report to the provider the following significant concerns: C. Urinary output, D. Reported pain level, and F. Vital signs. The client's urinary output is significantly low at only 15 mL since 1100, indicating possible urinary retention or inadequate kidney function, which could be due to effects from surgery, medications, or other complications. Additionally, the increase in reported pain level from 6 to 8 out of 10 despite administration of morphine suggests the pain management strategy is currently ineffective and needs to be reassessed. Lastly, the change in vital signs, particularly the increased heart rate from 76 to 116 beats per minute and decreased oxygen saturation from 95% to 93%, could be indicative of a number of complications, including pain response, infection, or other postoperative issues.