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A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Exhibit 1 Vital Signs Temperature 37.7° C(99.8°F) . Heart rate 82/min . Respiratory rate 16/min . Blood pressure 127/80 mm Hg . Oxygen saturation 99% on room air   Exhibit 2 Assessment Height 157.5 cm (62 in) Weight 90 kg(198 lb) Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities. Distended veins noted on right lower extremity.   Exhibit 3 Nurses' Notes Client reports pain at abdominal incision site as 4 on a 0 to 10 scale. Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching. Reports that right lower extremity pain has been intermittent for about the last 2 months. Denies current left lower extremity pain.

A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy. Exhibit 1 Vital Signs Temperature 37.7° C(99.8°F) . Heart rate 82/min . Respiratory rate 16/min . Blood pressure 127/80 mm Hg . Oxygen saturation 99% on room air   Exhibit 2 Assessment Height 157.5 cm (62 in) Weight 90 kg(198 lb) Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities. Distended veins noted on right lower extremity.   Exhibit 3 Nurses' Notes Client reports pain at abdominal incision site as 4 on a 0 to 10 scale. Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching. Reports that right lower extremity pain has been intermittent for about the last 2 months. Denies current left lower extremity pain.

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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Question

A nurse on a medical-surgical unit is caring for a client who is postoperative following an emergency appendectomy.

Exhibit 1

Vital Signs

Temperature 37.7° C(99.8°F)

. Heart rate 82/min

. Respiratory rate 16/min

. Blood pressure 127/80 mm Hg

. Oxygen saturation 99% on room air

 

Exhibit 2

Assessment

Height 157.5 cm (62 in)

Weight 90 kg(198 lb)

Bilateral lower extremities warm to touch, pedal pulses 2+ bilaterally. Spider veins noted on bilateral lower extremities.

Distended veins noted on right lower extremity.

 

Exhibit 3

Nurses' Notes

Client reports pain at abdominal incision site as 4 on a 0 to 10 scale.

Client also reports right lower extremity pain as 5 on a 0 to 10 scale, and itching.

Reports that right lower extremity pain has been intermittent for about the last 2 months.

Denies current left lower extremity pain.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take 1 Action to Take 2 Actions to Take Apply graduated compression stockings. Apply ice. Apply a warm compress. Elevate extremity. Prepare to administer an anticoagulant. * * Condition Most Likely Experiencing Potential Condition Buerger's disease Varicose veins Deep vein thrombosis Venous insufficiency K Parameter to Monitor 1 Parameter to Monitor 2 Parameters to Monitor Ecchymosis of right lower extremity Intermittent claudication of right lower extremity Painful vasospasms of right lower extremity Edema of right lower extremity Pruritis of right lower extremity
Transcribed Image Text:Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take 1 Action to Take 2 Actions to Take Apply graduated compression stockings. Apply ice. Apply a warm compress. Elevate extremity. Prepare to administer an anticoagulant. * * Condition Most Likely Experiencing Potential Condition Buerger's disease Varicose veins Deep vein thrombosis Venous insufficiency K Parameter to Monitor 1 Parameter to Monitor 2 Parameters to Monitor Ecchymosis of right lower extremity Intermittent claudication of right lower extremity Painful vasospasms of right lower extremity Edema of right lower extremity Pruritis of right lower extremity
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