A nurse is caring for a client on the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the need for an dropdown due to the client’s dropdown and dropdown.
Explanation & Rationale
Rationale for Correct Choices: Antibiotic prescription: The client is showing signs of a possible postoperative wound infection (fever, elevated WBC count, purulent discharge, tenderness), all of which warrant initiation of antibiotics to control local and systemic infection. WBC count: The WBC has increased significantly from 8,000/mm³ on day 1 to 14,800/mm³ by day 3, indicating a developing infectious or inflammatory process likely related to the surgical site. Temperature: The temperature has risen to 38.8°C (101.8°F) by day 3, suggesting a febrile response to infection, which aligns with the findings of purulent wound drainage and local tenderness. Rationale for Incorrect Choices: Laxative: Although the client hasn’t had a bowel movement, this is expected early in the postoperative period, especially with hypoactive bowel sounds. Laxatives are contraindicated until full bowel function returns. IV fluids: There is no evidence of fluid volume deficit skin turgor is normal, and vital signs are stable making IV fluids unnecessary at this time. Prescription for IV iron: While hemoglobin is low, there is no evidence of acute blood loss, and infection is the more urgent concern. Iron supplementation would be a longer-term consideration. Bowel sounds: Hypoactive bowel sounds are common after abdominal surgery and not in themselves a reason to start antibiotics. Blood pressure: Client's BP is stable and within acceptable range; it does not indicate infection or require antibiotic treatment. Skin turgor: Normal skin turgor suggests hydration is adequate, not an indication for antibiotic use. Transferrin level: While slightly decreased, this is a nonspecific finding and not indicative of acute infection or requiring antibiotics. Bowel movements: Absence of bowel movement alone post-surgery does not justify antibiotics; infection indicators are more critical.