A nurse is caring for a postoperative client who has developed peritonitis. An assessment finding that would require immediate action would be
A) a decrease in blood pressure of more than 15 mm Hg.
B) an increase in urine output of more than 300 ml/day.
C) pulse deficit of more than 20 beats/minute.
D) weight gain of more than 5 pounds.

Question

Quizplus · Accepted Answer

Postoperatively, the nurse should closely monitor the client for development of postoperative complications (e.g., adult respiratory distress syndrome [ARDS], sepsis, shock) by changes in vital signs, immediately reporting any manifestations of sepsis (e.g., decrease/increase in temperature, decrease in blood pressure). A urine output of only 300 ml in 1 day is below normal for an adult (30-50 ml/hr). Pulse deficit and weight gain would not indicate a common postoperative complication.

A Nurse Is Caring for a Postoperative Client Who Has