A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Exhibit 1 Vital Signs Temperature 37.7° C(99.8°F) . Heart rate 82/min . Respiratory rate 16/min . Blood pressure 127/80 mm Hg . Oxygen saturation 99% on room air Exhibit 2 Assessment Height 157.5 cm (62 in) Weight 90 kg(198 lb) Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities. Distended veins noted on right lower extremity. Exhibit 3 Nurses' Notes Client reports pain at abdominal incision site as 4 on a 0 to 10 scale. Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching. Reports that right lower extremity pain has been intermittent for about the last 2 months. Denies current left lower extremity pain.
A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Exhibit 1 Vital Signs Temperature 37.7° C(99.8°F) . Heart rate 82/min . Respiratory rate 16/min . Blood pressure 127/80 mm Hg . Oxygen saturation 99% on room air Exhibit 2 Assessment Height 157.5 cm (62 in) Weight 90 kg(198 lb) Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities. Distended veins noted on right lower extremity. Exhibit 3 Nurses' Notes Client reports pain at abdominal incision site as 4 on a 0 to 10 scale. Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching. Reports that right lower extremity pain has been intermittent for about the last 2 months. Denies current left lower extremity pain.
Chapter10: Cpt Anesthesia
Section: Chapter Questions
Problem 3MC
Related questions
Question
A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy.
Exhibit 1
Vital Signs
Temperature 37.7° C(99.8°F)
. Heart rate 82/min
. Respiratory rate 16/min
. Blood pressure 127/80 mm Hg
. Oxygen saturation 99% on room air
Exhibit 2
Assessment
Height 157.5 cm (62 in)
Weight 90 kg(198 lb)
Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities.
Distended veins noted on right lower extremity.
Exhibit 3
Nurses' Notes
Client reports pain at abdominal incision site as 4 on a 0 to 10 scale.
Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching.
Reports that right lower extremity pain has been intermittent for about the last 2 months.
Denies current left lower extremity pain.
Transcribed Image Text:Complete the diagram by dragging from the choices below to specify
what condition the client is most likely experiencing, 2 actions the nurse
should take to address that condition, and 2 parameters the nurse
should monitor to assess the client's progress.
Action to Take 1
Action to Take 2
Actions to Take
Apply graduated
compression
stockings.
Apply ice.
Apply a warm
compress.
Elevate
extremity.
Prepare to
administer an
anticoagulant.
*
*
Condition Most Likely
Experiencing
Potential Condition
Buerger's disease
Varicose veins
Deep vein
thrombosis
Venous
insufficiency
K
Parameter to Monitor 1
Parameter to Monitor 2
Parameters to Monitor
Ecchymosis of
right lower
extremity
Intermittent
claudication of
right lower
extremity
Painful
vasospasms of
right lower
extremity
Edema of right
lower extremity
Pruritis of right
lower extremity
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