A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention?

Choice A reason: Administering the medication over 1 minute is crucial for phenytoin IV administration. Phenytoin should be administered slowly to prevent severe cardiovascular reactions, including hypotension and arrhythmias. The recommended rate is not to exceed 50 mg per minute.

Choice B reason: Diluting the medication with sterile water before injecting is not recommended for phenytoin. Phenytoin should be administered undiluted or diluted with normal saline if necessary. Using sterile water can cause the medication to precipitate.

Choice C reason: Slowing the injection if the medication crystallizes is not an appropriate action. If phenytoin crystallizes, it should not be administered. The nurse should ensure the solution is clear before administration and discard any crystallized medication.

Choice D reason: Following the injection with sterile water is not necessary. Phenytoin does not require a flush with sterile water after administration. Instead, normal saline can be used to flush the IV line before and after administration to ensure the line is clear.

Choice A: Pain Level
The client reports a pain level of 7 on a scale of 0 to 10. Postoperative pain is expected, but a pain level of 7 indicates severe pain that requires immediate attention. Effective pain management is crucial for postoperative recovery as unmanaged pain can lead to complications such as increased heart rate, elevated blood pressure, and delayed
healing. The nurse should assess the effectiveness of the current pain management plan and consider administering additional analgesics or adjusting the pain management strategy. Pain should be reassessed frequently to ensure the client is comfortable and to prevent complications associated with severe pain.

Choice B: Blood Pressure
The client’s blood pressure is 138/72 mmHg, which is within the normal range for adults (systolic 90-120 mmHg and diastolic 60-80 mmHg). While slightly elevated, this blood pressure reading does not require immediate follow-up in the context of postoperative care unless there are other symptoms indicating a hypertensive crisis or other cardiovascular issues. It is important to monitor blood pressure regularly, but in this scenario, it is not one of the critical findings that require immediate intervention.

Choice C: Lung Sounds
Crackles heard upon auscultation in the posterior lungs and the client being dyspneic are significant findings that require immediate follow-up. Crackles can indicate fluid accumulation in the lungs, which may be a sign of pulmonary edema or pneumonia. Dyspnea, or difficulty breathing, further supports the need for urgent assessment and intervention. The nurse should perform a thorough respiratory assessment, monitor oxygen saturation levels, and notify the healthcare provider. Interventions may include administering supplemental oxygen, positioning the client to improve ventilation, and possibly initiating diuretic therapy if fluid overload is suspected.

Choice D: Incision Site
The incision site has purulent drainage, redness, and warmth, which are classic signs of infection. Postoperative infections can lead to serious complications, including sepsis if not promptly addressed. The nurse should assess the incision site for additional signs of infection, such as increased swelling, foul odor, or increased pain. The healthcare provider should be notified immediately to initiate appropriate interventions, which may include wound cultures, antibiotics, and possibly surgical intervention to manage the infection. Monitoring the client’s temperature and other vital signs is also essential to detect systemic infection early.

Choice E: Pedal Pulses
The client’s pedal pulses are +2 bilaterally, which is considered normal. Pedal pulses are assessed to evaluate peripheral circulation, and a +2 rating indicates normal pulse strength. There is no immediate concern regarding the client’s peripheral circulation based on this finding. However, it is important to continue monitoring peripheral pulses as part of routine postoperative care to ensure there are no changes that could indicate vascular complications.