Question

The nurse is caring for a client during the immediate post-operative period and notes the following assessment data:

T: 100.1
P: 112
RR: 24
BP: 86/48,
Pox 85% on 2 L NC
Circumoral pallor
cap refill > 3 sec
Dressing: large amount of bright red drainage.

Which of the following represents the priority nursing action?

a) Notify the surgeon immediately
b) Reinforce dressing site with gauze
c) Administer bolus dose of D5LR
d) Increase O2 to 4 liters as ordered

Answer 1

The priority nursing action is to notify the surgeon immediately, as the patient's assessment data suggest a potential hemorrhage or other serious post-operative complication.

Step-by-step explanation:

The priority nursing action when the nurse notices assessment data that includes a temperature of 100.1, pulse of 112, respiratory rate of 24, blood pressure of 86/48, oxygen saturation at 85% on 2 L nasal cannula, circumoral pallor, and a capillary refill time of greater than 3 seconds, plus a dressing with a large amount of bright red drainage, is to notify the surgeon immediately. These signs indicate the possibility of hemorrhage or other post-operative complications that require urgent intervention by the surgical team. The nurse should recognize that while reinforcing the dressing and increasing oxygen can be supportive measures, they must not delay communication with the surgeon, as the patient may need rapid surgical or medical intervention to manage potential bleeding and hypoxia.