Exhibits

A nurse is assisting with the care of a client in the emergency department. The client is alert and oriented x3. Wheezing is noted on exhalation with a prolonged breathing cycle. The cough is nonproductive. Use of accessory muscles is noted while breathing. The oral mucosa and lips are cyanotic. Nasal flaring is noted. The client experiences difficulty talking.

The nurse is assisting in planning care. Complete the diagram by dragging from the choices below to specify:

1. What condition the client is most likely experiencing.
2. Two actions the nurse should take to address that condition.
3. Two parameters the nurse should monitor to assess the client’s progress.

Choice A rationale

Hypoactive bowel sounds in all four quadrants are not unusual in a patient one day postoperative following an appendectomy. This is because anesthesia and surgery can slow down the bowel movements temporarily.

Choice B rationale

Red streaks along the incision are a sign of infection. This could indicate cellulitis, a common skin infection that can be serious if left untreated. The red streaks are often warm to the touch and may be accompanied by other signs of infection such as fever, pain, and swelling.

Therefore, the nurse should report this finding.

Choice C rationale

Serosanguineous drainage at the incision site is not uncommon in the first few days after surgery. It is a mixture of blood and serum and is usually light pink to blood-tinged in color. However, if the drainage is heavy, or if it continues for more than a few days, it could be a sign of a problem such as infection or poor wound healing.

Choice D rationale

A temperature of 37.2 C (99 F) is within the normal range for body temperature. A slight elevation in temperature can be expected after surgery due to the body’s inflammatory response to the surgical trauma.

A. Sore throat: A sore throat is a common side effect following a bronchoscopy due to irritation of the airway. It is typically expected and does not indicate a serious complication.

B. Presence of gag reflex: The return of the gag reflex after a bronchoscopy is a normal finding. It indicates that the protective airway reflexes are intact, which is a positive sign.

C. Blood pressure 110/88 mm Hg: Although the diastolic pressure is a bit high, this blood pressure reading is generally acceptable post-procedure and is not typically concerning in the context of a bronchoscopy.

D. Facial edema: Facial edema is not a normal finding following a bronchoscopy. It may indicate an allergic reaction, adverse response to medications used during the procedure, or a complication such as airway edema. This finding should be reported immediately to the healthcare provider as it could signal a potentially serious condition.