A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?

Rationale for Correct Choices:

• Pain radiating to the back, worsens after eating or lying down: This is characteristic of acute pancreatitis, where inflammation irritates surrounding tissues and worsens in the supine position due to gravitational pressure. Postprandial worsening suggests pancreatic enzyme stimulation.
• Scleral icterus (yellow sclera and palate): Jaundice suggests biliary obstruction or liver involvement, possibly due to gallstone pancreatitis or alcoholic liver disease. This also aligns with the elevated bilirubin levels and warrants further hepatic and biliary assessment.
• Abdomen distended, rigid, and tender with guarding: These are signs of peritonitis or severe intra-abdominal inflammation, requiring urgent evaluation. Guarding and rigidity indicate localized or diffuse peritoneal irritation from pancreatic enzymes.
• Hypoactive bowel sounds: Reduced bowel activity is often seen in pancreatitis due to paralytic ileus caused by inflammation and stress response. Monitoring for progression to ileus or obstruction is necessary.
• Client guards abdomen and grimaces during palpation: Guarding and pain upon palpation are signs of significant intra-abdominal inflammation. It may reflect worsening pancreatitis or complications such as necrosis or peritonitis.

Rationale for Incorrect Choices:

• Heart rate regular, lungs clear to auscultation: These are normal findings and do not require follow-up.
• Client is alert and oriented x4: Indicates normal neurologic status. No immediate concern here.
• Reports no recent illnesses, takes no prescribed medications: This helps rule out medication-induced pancreatitis and doesn't indicate a need for follow-up.

Rationale for Correct Choices:

• Antibiotic prescription: The client is showing signs of a possible postoperative wound infection (fever, elevated WBC count, purulent discharge, tenderness), all of which warrant initiation of antibiotics to control local and systemic infection.
• WBC count: The WBC has increased significantly from 8,000/mm³ on day 1 to 14,800/mm³ by day 3, indicating a developing infectious or inflammatory process likely related to the surgical site.
• Temperature: The temperature has risen to 38.8°C (101.8°F) by day 3, suggesting a febrile response to infection, which aligns with the findings of purulent wound drainage and local tenderness.

Rationale for Incorrect Choices:

• Laxative: Although the client hasn’t had a bowel movement, this is expected early in the postoperative period, especially with hypoactive bowel sounds. Laxatives are contraindicated until full bowel function returns.
• IV fluids: There is no evidence of fluid volume deficit skin turgor is normal, and vital signs are stable making IV fluids unnecessary at this time.
• Prescription for IV iron: While hemoglobin is low, there is no evidence of acute blood loss, and infection is the more urgent concern. Iron supplementation would be a longer-term consideration.
• Bowel sounds: Hypoactive bowel sounds are common after abdominal surgery and not in themselves a reason to start antibiotics.
• Blood pressure: Client's BP is stable and within acceptable range; it does not indicate infection or require antibiotic treatment.
• Skin turgor: Normal skin turgor suggests hydration is adequate, not an indication for antibiotic use.
• Transferrin level: While slightly decreased, this is a nonspecific finding and not indicative of acute infection or requiring antibiotics.
• Bowel movements: Absence of bowel movement alone post-surgery does not justify antibiotics; infection indicators are more critical.