The practical nurse (PN) finds a postoperative client lying in bed with an unsecured surgical dressing as seen in the picture. After reinforcing the dressing, which follow-up assessment is most important for the PN to implement?
Vital sign measurement.
Fluid volume intake and output.
Volume of peripheral pulses.
Incisional pain scale rating.
The Correct Answer is A
This is the most important follow-up assessment for the PN to implement because it can detect signs of bleeding, infection, or shock that may result from the unsecured surgical dressing. The PN should monitor the client's blood pressure, pulse, temperature, and respiratory rate and report any abnormal changes.
B. Fluid volume intake and output is not the most important follow-up assessment for this client and may not reflect the current status of the client's fluid balance or blood loss.
C. Volume of peripheral pulses is not the most important follow-up assessment for this client and may not be affected by the unsecured surgical dressing unless it is located on a limb or near a major artery.
D. Incisional pain scale rating is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.
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Correct Answer is D
Explanation
This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment.
The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.
Correct Answer is D
Explanation
The correct answer is Choice D
Choice A: Excruciating pain
- Rationale: While partial thickness burns can be painful, especially in the first few days, excruciating pain is less likely for a stable patient 3 days post-burn. Pain management is a crucial aspect of burn care, but excruciating pain might indicate deeper burns or complications like infection.
Choice B: Elevated blood pressure
- Rationale: Elevated blood pressure is not a typical complication of a partial thickness burn. In fact, burn patients are more at risk for hypotension (low blood pressure) due to fluid loss.
Choice C: Compartment syndrome
- Rationale: Compartment syndrome is a serious complication that typically occurs with deep burns or traumatic injuries. It's caused by increased pressure within a muscle compartment, restricting blood flow and potentially leading to tissue death. While a possibility, it's less likely for a partial thickness burn 3 days after the injury.
Choice D: Curling's Ulcer
- Rationale: Curling's ulcer is a peptic ulcer (stomach ulcer) that can develop as a complication of major burns. This is because burns trigger a massive inflammatory response, releasing stress hormones that increase stomach acid production, making the stomach lining more susceptible to ulcers. Given the extensive burn area (30% TBSA) and the timeframe (3 days post-burn), Curling's ulcer becomes a significant concern.
Therefore, the correct answer is: Choice D: Curling's Ulcer
Explanation:
- A 30% TBSA partial thickness burn is a significant injury that triggers a systemic inflammatory response.
- Three days post-burn falls within the timeframe when Curling's ulcer can develop due to the increased stress hormones and gastric acid production.
- While pain management and monitoring for compartment syndrome are important, Curling's ulcer poses a more significant threat in this scenario.
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