A nurse is caring for a client.

Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

1500:

Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.

1730:

Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.

Vital Signs

1730:

• Temperature 37.2° C (98.9° F)
• Blood pressure 168/84 mm Hg
• Heart rate 116/min
• Respiratory rate 24/min
• Oxygen saturation 93% on room air

Choice A reason:
A. Place the tourniquet below the proposed insertion site.
When preparing to insert an IV catheter, placing the tourniquet below the proposed insertion site helps facilitate venous distension, making it easier to locate and access a suitable vein for catheter insertion.
Choice B reason:
Placing the extremity in a dependent position (lower than the heart) can increase venous pressure and make it more difficult to insert the catheter.
Choice C reason:
Choosing the most proximal site on the extremity is not always necessary or appropriate. Veins distal to the proposed insertion site should be considered first, as they tend to be smaller and less accessible.
Choice D reason:
Applying a cool compress is not typically done before IV catheter insertion. It might cause vasoconstriction and make it more difficult to access a suitable vein.

Choice A reason:
Wearing a mask when outside of the room is not a standard practice for all patients undergoing an allogeneic stem cell transplant. The need for mask use may vary based on the patient's specific condition and the facility's infection control protocols.
Choice B reason:
"You will be in a negative-airflow room to keep the air cleaner." This is the appropriate answer. An allogeneic stem cell transplant involves replacing the patient's damaged or diseased bone marrow with healthy donor stem cells. Patients undergoing this type of transplant have compromised immune systems due to the treatment, which increases the risk of infection. Placing the patient in a negative-airflow room helps prevent the spread of airborne infections by ensuring that air flows into the room but does not escape into other areas of the facility
Choice C reason:
Visitors wearing protective gowns is not a standard practice for all patients undergoing an allogeneic stem cell transplant. Visitor guidelines may depend on the patient's immune status and specific infection control measures.
Choice D reason:
Being placed in a semi-private room is not recommended for patients undergoing an allogeneic stem cell transplant. These patients require a controlled environment to reduce the risk of infections, and private rooms with proper infection control measures are generally preferred.