Management of Care Q 17
Nurse Sarah is caring for clients on the surgical floor and has just received a report from the previous shift. Which of the following clients should the nurse see first?
A. A 35-year-old admitted three hours ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.
B. A 43-year-old who had a mastectomy two days ago; 23 ml of serosanguinous fluid noted in the Jackson-Pratt drain.
C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours.
D. A 62-year-old who had an abdominal-perineal resection three days ago; client complaints of chills.
Correct Answer: D. A 62-year-old who had an abdominal-perineal resection three days ago; client complains of chills.
The client is at risk for peritonitis; should be assessed for further symptoms and infection.
Option A: The client may be hemorrhaging on his wound; this needs further assessment but does not require urgent attention.
Option B: Serosanguinous fluid on the drain is a normal finding.
Option C: Absence of drainage on a client with collapsed lung is normal; the chest tube is for the removal of air inside the lung.