A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client’s vital signs are temperature 38.3°C (100.9°F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse’s priority?
A.
Notify the surgeon of the temperature elevation.
B.
Encourage the client to drink more fluids.
C.
Assess the surgical incision for signs of infection.
D.
Monitor vital signs every 4 hr.
The Correct Answer and Explanation is:
Correct Answer: C. Assess the surgical incision for signs of infection.
Explanation:
The priority action in this scenario is to assess the surgical incision for signs of infection (Option C). Here’s why:
- Post-Surgical Infection Risk: After a surgical procedure such as the repair of an abdominal aortic aneurysm, the patient is at increased risk for postoperative infections. The client’s elevated temperature of 38.3°C (100.9°F) indicates a possible fever, which is a common sign of infection. Given that the surgery was only 3 days ago, it’s crucial to promptly identify and address any signs of infection at the incision site, as infections can rapidly escalate if not treated.
- Assessing the Incision: By inspecting the surgical site, the nurse can identify clinical signs of infection such as redness, warmth, swelling, increased pain, or discharge. Early detection of these signs allows for timely intervention, such as initiating appropriate antibiotics, which is crucial for preventing complications like sepsis or delayed healing.
- Additional Actions: While notifying the surgeon (Option A) might eventually be necessary if an infection is suspected, the immediate action should be to gather more information through a physical assessment. Encouraging fluid intake (Option B) and monitoring vital signs every 4 hours (Option D) are important but secondary to the need to rule out or confirm a possible infection, which directly impacts patient outcomes.
- Priority in Nursing Care: In the nursing process, prioritizing actions is based on assessing the situation’s urgency and potential for harm. In this case, assessing the incision addresses a potential immediate complication (infection) that could lead to severe consequences if not managed promptly.
In summary, assessing the surgical incision for signs of infection is the most critical action for the nurse to take in this scenario to ensure the client’s safety and effective recovery.