A nurse is caring for a patient who has just returned from the operating room after a major abdominal surgery. The nurse notices that the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, oxygen saturation is 92%, and urine output is 20 mL/h. What is the nurse's priority action?

Choice A reason:

Keeping the dressing clean and dry prevents contamination and infection of the wound. It also helps the wound heal faster by protecting it from further injury. This is a standard instruction for wound care after a minor surgical procedure.

Choice B reason:

Changing the dressing every day or as needed helps keep the wound clean and allows the doctor or nurse to monitor the healing process. It also prevents the dressing from sticking to the wound or becoming too wet or soiled. This is another common instruction for wound care after a minor surgical procedure.

Choice C reason:

Washing the wound with soap and water is not recommended for wound care after a minor surgical procedure. Soap can irritate the wound and delay healing. Water can wash away the protective scab and cause bleeding. The wound should be rinsed with sterile water or saline solution instead.

Choice D reason:

Applying antibiotic ointment to the wound is not advised for wound care after a minor surgical procedure unless prescribed by the doctor or surgeon. Antibiotic ointment can cause allergic reactions, increase resistance to bacteria, or interfere with the healing process. The wound should be covered with a sterile dressing and left alone.

Choice E reason:

Reporting any signs of infection to the physician or surgeon is an important instruction for wound care after a minor surgical procedure. Signs of infection include redness, swelling, warmth, pain, pus, fever, or foul odor. Infection can delay healing, cause complications, or spread to other parts of the body.

Choice A reason:

Atelectasis is the collapse of alveoli in the lungs, which can impair gas exchange and cause hypoxia. It can occur after surgery due to anesthesia, pain, or immobility. However, atelectasis does not usually cause fever and chills, unless it is complicated by pneumonia.

Choice B reason:

Dehydration is the loss of fluid and electrolytes from the body, which can affect blood pressure, heart rate, and kidney function. It can occur after surgery due to blood loss, vomiting, or inadequate intake. However, dehydration does not usually cause fever and chills, unless it is associated with infection or heat stroke.

Choice C reason:

Inflammation is the body's response to tissue injury or infection, which involves increased blood flow, swelling, pain, and heat. It can occur after surgery as part of the normal healing process. However, inflammation does not usually cause fever and chills, unless it is severe or systemic.

Choice D reason:

Infection is the invasion and multiplication of microorganisms in the body, which can trigger an immune response and cause inflammation, fever, and chills. It can occur after surgery due to contamination of the surgical site, catheters, or intravenous lines. Infection is the most likely cause of fever and chills in a postoperative patient.