A nurse is monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?

Choice A reason:

This is incorrect because wound dehiscence is not normal and expected at this stage of healing. Wound dehiscence is a surgical complication where an incision reopens either internally or externally. It can interfere with wound healing and pose a threat to the individual's overall health. Wound dehiscence can be partial or complete, depending on how many layers of tissue are separated. In rare cases, wound dehiscence can lead to evisceration, which is when internal organs push out through the wound.

Choice B reason:

This is correct because wound dehiscence could be a sign of dehiscence, which is a medical emergency that requires immediate attention. The nurse should call the doctor right away and monitor the patient for signs of infection, bleeding, or evisceration. The nurse should also cover the wound with a sterile dressing moistened with saline to prevent further contamination and keep the patient calm and comfortable.

Choice C reason:

This is incorrect because coughing and deep breathing can increase the abdominal pressure and worsen the wound separation. The nurse should avoid any activities that can strain the stitches or staples used to hold the wound closed while it heals. The nurse should also instruct the patient to avoid vomiting, heavy lifting, or any sudden movements that can cause further damage to the wound.

Choice D reason:

This is incorrect because applying pressure on the wound can cause more bleeding or damage to the tissues. The nurse should not touch the wound or try to close it by themselves. The nurse should only cover the wound with a sterile dressing moistened with saline and wait for the doctor's instructions. Applying pressure on the wound can also increase the risk of infection or evisceration.

C. Notify the physician or surgeon.

Choice A reason:

Administer oxygen via nasal cannula. This is not the priority action because the patient's oxygen saturation is 92%, which is within the normal range of 90% to 100%. Oxygen therapy may be helpful, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria.

Choice B reason:

Increase the rate of intravenous fluids. This is not the priority action because the patient may have fluid overload or bleeding as a result of the major abdominal surgery. Increasing the rate of intravenous fluids without knowing the patient's fluid status and blood loss may worsen the patient's condition and lead to complications such as pulmonary edema, heart failure, or hemorrhage.

Choice C reason:

Notify the physician or surgeon. This is the priority action because the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, and urine output is 20 mL/h. These are signs of hypovolemic shock, which is a life-threatening condition that occurs when there is inadequate blood volume to maintain tissue perfusion. Hypovolemic shock can be caused by hemorrhage, dehydration, burns, or severe vomiting and diarrhea. The patient needs immediate medical attention and interventions such as blood transfusion, fluid resuscitation, vasopressors, and surgery to stop the bleeding source.

Choice D reason:

Administer pain medication. This is not the priority action because the patient's pain level is not mentioned in the question. Pain medication may be indicated for postoperative pain management, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria. Pain medication may also lower the blood pressure further and mask the signs of shock.