Question

You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post-op or pre-op for surgery. Which assessment finding requires further nursing action?

A. Orange-colored urine in a patient who is taking Pyridium and is post-op day 3 from a TURP.

B. No stool excretion in a patient who is post-op day 2 from a colostomy.

C. Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy.

D. Pain rating that has decreased from a 10 to 1 in a patient who is awaiting an appendectomy.

Answer 1

The pain rating decrease from a 10 to 1 in a patient awaiting an appendectomy is the most concerning assessment finding, requiring further nursing action as it may indicate a ruptured appendix.

Step-by-step explanation:

When evaluating which assessment finding requires further nursing action among post-op or pre-op patients, it's essential to identify abnormalities that may indicate complications or urgent issues. Let's examine the options:

• Orange-colored urine in a patient taking Pyridium post-op from a Transurethral Resection of the Prostate (TURP) is expected, as Pyridium can change the color of urine.
• No stool excretion in a patient who is post-op day 2 from a colostomy may not be unusual, as bowel movements can take time to resume after such surgery.
• Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy is common due to the referred pain from the gas used in the procedure.
• Pain rating decreased from a 10 to 1 in a patient awaiting an appendectomy requires immediate further nursing action. This could indicate a rupture, which is potentially life-threatening and requires prompt medical attention.

Therefore, the pain rating decrease in the patient awaiting an appendectomy is the assessment finding that demands urgent nursing action.