Difficulty: Medium
Average Score: 93%
Simulated
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider first?
Correct answer
B
Rationale
The correct answer is B: The client has a separation of their surgical incision. This finding should be reported first because it suggests a potential complication such as wound dehiscence, which can lead to serious consequences like infection or evisceration. Prompt intervention is necessary to prevent further complications.
A: The client's temperature of 38.3┬░C indicates a low-grade fever, which is concerning but not as urgent as a wound separation.
C: 3+ pitting edema in the lower extremities is indicative of fluid overload, which is important but not as immediately critical as a wound separation.
D: A urine output of 20 mL/hr is below the normal range, indicating possible renal impairment, but it is not as urgent as managing a wound separation.
A: The client's temperature of 38.3┬░C indicates a low-grade fever, which is concerning but not as urgent as a wound separation.
C: 3+ pitting edema in the lower extremities is indicative of fluid overload, which is important but not as immediately critical as a wound separation.
D: A urine output of 20 mL/hr is below the normal range, indicating possible renal impairment, but it is not as urgent as managing a wound separation.