A nurse receives the following change-of-shift morning report for the assigned clients. Which client should the nurse assess first?

Question

Quizplus · Accepted Answer

Low urine output in the first 24 hours after surgery is expected due to fluid restriction before surgery, hormonal responses to the physiological stress of surgery, and fluid losses during surgery. Urine output should increase by the second postoperative day. The total intravenous intake for this client for the last 24 hours is 3000 mL (125 mL x 24 hours). The urine output for an adult of average weight (154 lb [70 kg]) should be at least 0.5 mL/kg/hr (ie, 70 kg x 0.5 mL/hr = 35 mL/hr x 8 hours = 280 mL in 8 hours). This client is becoming oliguric (100 mL in 8 hours). The nurse should take vital signs to assess for hypotension, which can result in decreased renal perfusion, prerenal failure, and acute kidney injury, and assess for bladder distension and Foley catheter patency before notifying the health care provider (HCP). This assessment takes priority due to the potential for prerenal failure and acute kidney injury. (Option A) Auscultating fine crackles in the base of the lungs is common 1 day postoperative and is usually related to atelectasis caused by hypoventilation, especially in a client who has not yet ambulated. This assessment does not take priority. (Option B) A surgical dressing with serosanguineous drainage and a low-grade temperature related to the inflammatory response due to stress of surgery are expected findings 1 day postoperative. This assessment does not take priority. (Option C) Epidural analgesia (eg, continual, intermittent bolus, patient-controlled) provides excellent long-lasting postoperative pain control as it distributes the opioid medication directly to the opioid receptors in the spinal cord through a catheter placed in the epidural space. The nurse will perform a pain assessment and report to the anesthesia HCP, as a bolus of pain medication through the catheter may be needed. This assessment does not take priority. Educational objective: Low-grade temperature, serosanguineous wound drainage, fine crackles in the lung bases on auscultation, and decreased urine output are expected findings during the first 24-hour postoperative period. If the client has decreasing urine output with oliguria (<400 mL/24 hr) by the second postoperative day, the nurse assesses for hypotension and for bladder distension and Foley catheter patency.

A Nurse Receives the Following Change-Of-Shift Morning Report for the Assigned