The nurse determines that an adult client who is admitted to the postanesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.8°C), a heart rate of 88 beats per minute, a respiratory rate of 14 breaths per minute, and a blood pressure of 94/68 mm Hg. Which intervention should the nurse implement first?

Condition:

Postoperative infection

2 Actions:

1. Administer prescribed antibiotics.
2. Culture wound drainage.

2 Parameters:

1. Temperature.
2. White blood cell count.

Rationale for correct condition:

A postoperative infection is the most likely condition because the patient has elevated white blood cell count (11,000/mm³) and a slightly elevated temperature (99.8°F). These findings suggest a systemic inflammatory response, potentially from infection. The presence of a recent surgical wound increases the risk of bacterial contamination. The absence of redness or drainage does not rule out deeper tissue infection. The patient’s symptoms align with early signs of an infectious process.

Rationale for the two correct actions:

1. Administer prescribed antibiotics: Antibiotics target potential bacterial infection, which is critical to prevent further complications such as systemic infection or sepsis.
2. Culture wound drainage: This identifies the causative organism and guides appropriate antibiotic therapy. Even if the wound appears clean externally, culturing can confirm or rule out deeper infection.

Rationale for parameters to monitor:

1. Temperature: Monitoring temperature helps identify trends in fever, a common sign of infection progression or resolution.
2. White blood cell count: Elevated levels are a marker of infection or inflammation. Monitoring changes in WBC count can indicate if treatment is effective.

Rationale for incorrect conditions:

1. Surgical rash: A rash is not indicated in the notes, and the elevated WBC count and temperature do not suggest a dermatologic issue.
2. Contractures: No evidence suggests reduced mobility or positioning problems causing contractures.
3. Deep vein thrombosis (DVT): The client’s normal vital signs and lack of redness or swelling in the residual limb make DVT less likely.

Rationale for incorrect actions to take:

1. Request NPO prescription: There is no evidence of gastrointestinal issues or surgery requiring this intervention.
2. Elevate residual limb to reduce swelling: While useful in managing swelling, there is no current sign of significant limb edema requiring elevation.
3. Educate on incentive spirometer use: This is preventive for respiratory complications but unrelated to infection management.

Rationale for incorrect parameters to monitor:

1. Adherence to activity prescription: While important for recovery, it does not directly address infection.
2. Residual limb redness or swelling: Although relevant to infection, there is no current evidence of redness or swelling in the notes.
3. Pain intensity and characteristics: Pain is already being managed with morphine, and its current level (5/10) does not directly indicate infection.

Choice A reason: A cerebrovascular accident (CVA), commonly known as a stroke, occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Although a severe headache might be a symptom of a stroke, it does not typically present with fever, nuchal rigidity, and a petechial rash, which are more indicative of an infection or inflammatory process.

Choice B reason: Meningococcal meningitis is a bacterial infection that causes inflammation of the membranes covering the brain and spinal cord. Symptoms often include a severe headache, fever, neck stiffness (nuchal rigidity), and a petechial rash, which is a distinguishing feature. This condition is a medical emergency and requires prompt antibiotic treatment to prevent serious complications or death.

Choice C reason: Intracerebral hemorrhage is bleeding within the brain tissue itself, which can be caused by various factors such as hypertension, aneurysms, or trauma. While it can cause a severe headache and neurological symptoms, it does not typically present with fever, nuchal rigidity, and a petechial rash, which suggest an infectious etiology rather than a hemorrhagic one.

Choice D reason: Rocky Mountain spotted fever is a tick-borne illness caused by the bacterium Rickettsia rickettsii. It can present with fever, headache, and a rash, but the rash is typically more generalized and not petechial. Additionally, the presence of nuchal rigidity and severe headache are more characteristic of meningitis rather than Rocky Mountain spotted fever.