Patient Data

 

Exhibits

The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

A. Encourage positive self accolades for dietary adherence: While supportive reinforcement is helpful for long-term behavior change, it does not address the immediate problem of vomiting and inability to tolerate food and liquids.

B. Determine if the client is over-hydrating to feel satiated: Assessing hydration habits may be part of long-term dietary counseling, but it is not the priority intervention when the client is acutely vomiting and unable to tolerate intake.

C. Maintain the client on an NPO status: Keeping the client NPO prevents further vomiting, reduces the risk of aspiration, and allows the gastrointestinal tract to rest. This is the immediate priority intervention in managing post-bariatric surgery complications such as obstruction or delayed gastric emptying.

D. Administer daily vitamin supplements: Vitamins are important for nutritional maintenance after bariatric surgery, but administering them orally is not appropriate when the client cannot tolerate food or liquids. Nutritional support should be deferred until tolerance improves.

Rationale for correct choices:

• Infection: The client presents with redness, warmth, swelling, and pain in the left lower leg, accompanied by a small cut and a history of type 2 diabetes. These findings, along with elevated temperature and glucose, indicate a bacterial skin infection requiring prompt treatment with antibiotics to prevent progression.

• Sepsis: Older adults with diabetes and chronic comorbidities are at high risk for systemic infection. The client’s generalized muscle aches, fever, and elevated glucose may indicate early systemic involvement. Interventions to prevent sepsis, such as timely IV antibiotics, monitoring vital signs, and laboratory markers (e.g., WBC, lactate), are crucial to reduce life-threatening complications.

Rationale for incorrect choices:

• Congestive heart failure: While the client has a history of heart failure, the acute presentation of erythema, warmth, and localized swelling suggests infection rather than fluid overload as the priority concern. CHF management is important but secondary in this scenario.

• Kidney disease: Stage 3a chronic kidney disease is a chronic condition and does not explain the acute signs of infection. Monitoring kidney function is important for medication dosing, but it is not the immediate priority.

• Hyperglycemia: The client’s blood glucose is elevated at 252 mg/dL, likely worsened by stress and infection. Hyperglycemia requires monitoring and management, but the underlying infection poses a more immediate threat to health.

• Deep vein thrombosis: DVT can cause leg swelling and pain, but the presence of erythema, warmth, and a break in the skin indicates cellulitis rather than thrombus formation. DVT prevention may be part of ongoing care but is not the priority in this acute presentation.

• Peripheral neuropathy: The client has baseline neuropathy contributing to bilateral leg discomfort, but it does not explain the acute swelling, redness, and warmth. Pain management may be necessary, but infection treatment is urgent.

• Edema: Edema is a symptom present in several chronic conditions, including CHF and PVD, but in this case, localized edema is part of the infection process. Addressing the infection takes priority over general edema management.