A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
Explanation & Rationale
A. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site: Moderate pain is expected after bowel surgery and can be managed with prescribed analgesics. While pain should be monitored and treated, it is not immediately life-threatening or the priority concern. B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr: Small amounts of dark red drainage are common in the early postoperative period due to normal oozing from the surgical site. This finding should be documented and monitored but does not require urgent intervention unless it increases significantly. C. The client arouses easily but quickly falls back asleep: Altered level of consciousness can indicate serious complications such as bleeding, hypoxia, or anesthetic effects. This change is potentially life-threatening and requires immediate reporting to the provider, making it the priority finding. D. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr: This urine output is below expected but can be consistent with mild postoperative fluid shifts or dehydration. It should be monitored, but it is not the most urgent concern compared with the change in mental status.