Question

A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply) [16]

1. The skin around the wound is tender to touch
2. Fluid intake for 8 hours is 800 mL
3. Patient has a heart rate of 78 and regular
4. Patient has drainage from surgical wound
5. Body temperature is 101F (38.3 C)
6. Patient asks, "I'm worried that I won't return to work when I planned."

Answer 1

The cues that form a pattern suggesting a problem are tender skin around the wound, decreased fluid intake, drainage from the surgical wound, and elevated body temperature.

Step-by-step explanation:

Based on the assessment data provided, the cues that form a pattern suggesting a problem are:

1. The skin around the wound is tender to touch: This could indicate an infection or inflammation at the surgical wound site.
2. Fluid intake for 8 hours is 800 mL: This suggests a decreased fluid intake, which may indicate dehydration or another underlying issue.
3. The patient has drainage from the surgical wound: Drainage from a surgical wound could indicate an infection or inadequate wound healing.
4. Body temperature is 101F (38.3 C): An elevated body temperature can be a sign of infection or inflammation.

The other cues provided, such as a regular heart rate and a patient expressing worry about returning to work, do not necessarily indicate a specific problem.