When monitoring a client's abdominal incision, the practical nurse (PN) observes a large amount of sanguineous drainage on the dressing. Which client data collection should the PN complete first?
Explanation & Rationale
The correct answer is Choice A. Temperature. Choice A rationale: The practical nurse (PN) should complete the data collection for temperature first. A large amount of sanguineous drainage on the abdominal incision dressing could indicate possible infection or a change in the client's condition. Elevated temperature may be an early sign of infection, which requires immediate attention and appropriate intervention. Choice B rationale: Assessing the pain scale is important, but it can be addressed after completing the data collection for temperature. Pain assessment is essential for providing appropriate pain management, but it is not the most urgent concern when there is a significant amount of drainage from the incision site. Choice C rationale: Checking bowel sounds is relevant in postoperative care, but it is not the priority at this moment. Abdominal incision drainage takes precedence as it may indicate a more critical issue that requires immediate attention. Choice D rationale: Monitoring blood pressure is essential, but it is not the most immediate concern in this scenario. A large amount of sanguineous drainage from the abdominal incision takes precedence over blood pressure monitoring at this time.