Question

While assisting a client who recently had a hip replacement into a bedpan, the nurse noticed a small amount of bloody drainage on the surgical dressing, the client’s skin was warm to the touch, and there was a strong odor from the urine. Which action should the nurse take?

a. Obtain a urine sample from the bedpan
b. Remove the dressing and assess the surgical site
c. Insert an indwelling urinary catheter
d. Measure the client’s oral temperature

Answer 1

The nurse should measure the client's oral temperature to check for an indication of infection, in addition to reporting the findings to the healthcare team for further assessment and possible treatment of an infection.

Step-by-step explanation:

When a nurse notices a small amount of bloody drainage on a surgical dressing, warm skin to the touch, and strong odor from urine in a client who recently had a hip replacement, the appropriate action to take would be to measure the client’s oral temperature. These signs suggest the possibility of an infection, which may be systemic or localized. The elevated temperature can be a significant indicator of an infection, along with the direct observations. If an infection is suspected, further assessment and tests should be conducted to determine the appropriate treatment. For example, as per the provided Clinical Focus cases, obtaining a urine sample may be critical for diagnosing a urinary tract infection (UTI) and determining the right antibiotic therapy.

However, it is also important for the nurse to report these findings to the healthcare team so that a comprehensive assessment can be made, and appropriate treatment can be delivered if an infection is diagnosed.