Which of the following post-surgical clients warrant an immediate follow up by the nurse? (Select all that apply.)

Patient with lung surgery has 20 ml/hr of urine output via catheter.

Patient with appendix surgery has thready pulse and blood pressure is 90/60.

Patient with knee surgery has approximated incision.

Patient with femoral artery surgery has strong pedal pulse.

Patient with bladder surgery has bloody urine within the first 12 hours.

Answer and Explanation

Correct Answer : A,B,E

A.   A urine output of 20 ml/hr is considered inadequate and may indicate decreased kidney perfusion or function. This client likely needs immediate assessment and intervention to address potential renal complications.
B.   A patient with appendix surgery exhibiting a thready pulse and a blood pressure of 90/60 should be followed up immediately, as these signs can indicate shock, which is a medical emergency.
C.   An approximated incision indicates that the wound edges are well-aligned and healing is progressing as expected. This does not typically warrant immediate follow-up unless there are signs of infection or other complications.
D.   A strong pedal pulse suggests adequate blood flow distal to the surgical site. This is a positive finding and does not typically require immediate follow-up unless there are signs of vascular compromise or other complications.
E.   A patient with bladder surgery having bloody urine within the first 12 hours can be expected, but if the bleeding is heavy or increases, it would warrant immediate follow-up.

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Correct Answer is C

Explanation

A. A hematocrit of 40% is within the normal range for females, which is typically around 37-47%. This result is not concerning and does not typically require immediate notification to the surgeon.
B. A creatinine level of 0.9 mg/dL is within the normal range for adults (normal range varies slightly among laboratories but is generally around 0.5-1.1 mg/dL). This result indicates normal kidney function and does not require immediate notification.
C. A white blood cell (WBC) count of 20,000/mm3 is elevated above the normal range, which is typically between 4,500-11,000/mm3. An elevated WBC count could indicate infection or inflammation. Given the client is preoperative, an elevated WBC count may suggest an underlying infection that needs to be addressed before proceeding with surgery. The nurse should notify the surgeon promptly so appropriate evaluation and management can be initiated.
D. A potassium level of 3.8 mEq/L is within the normal range (normal range is generally 3.5-5.0 mEq/L). This result is not concerning and does not require immediate notification to the surgeon.

A. Use IV tubing specific for heparin sodium when administering the infusion. B. Administer 50,000 units of heparin by IV bolus every 12 hr. C. Have vitamin K available on the nursing unit. D. Check the activated partial thromboplastin time (aPTT) every 4 hr.

Correct Answer is D

Explanation

A. Heparin should be administered using IV tubing that is specifically labeled for heparin or that has been dedicated for anticoagulant use only. However, this is not the most important action.

B. Heparin is not typically administered as a bolus (large single dose) because of its rapid onset of action and potential for causing bleeding complications. Instead, heparin is usually administered as a continuous IV infusion to achieve and maintain therapeutic anticoagulation.
C. While vitamin K is an antidote for reversing the effects of warfarin (a different type of anticoagulant), it is not used for reversing the effects of heparin. The reversal agent for heparin is protamine sulfate. Therefore, having vitamin K available is not necessary for managing a client receiving heparin.
D. The aPTT is a laboratory test used to monitor the therapeutic effect of heparin therapy. It measures the clotting time of blood and helps ensure that the client's heparin infusion is within the desired therapeutic range. Checking aPTT regularly (usually every 4-6 hours initially, then adjusting based on results) is essential to maintain therapeutic anticoagulation and avoid complications like bleeding or clotting.

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Which of the following post-surgical clients warrant an immediate follow up by the nurse? (Select all that apply.)

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