A home health nurse is assisting in the care of a patient following a modified radical mastectomy. Which statement by the patient indicates effective coping?

Choice A rationale

Hypoactive bowel sounds in all four quadrants are not unusual in a patient one day postoperative following an appendectomy. This is because anesthesia and surgery can slow down the bowel movements temporarily.

Choice B rationale

Red streaks along the incision are a sign of infection. This could indicate cellulitis, a common skin infection that can be serious if left untreated. The red streaks are often warm to the touch and may be accompanied by other signs of infection such as fever, pain, and swelling.

Therefore, the nurse should report this finding.

Choice C rationale

Serosanguineous drainage at the incision site is not uncommon in the first few days after surgery. It is a mixture of blood and serum and is usually light pink to blood-tinged in color. However, if the drainage is heavy, or if it continues for more than a few days, it could be a sign of a problem such as infection or poor wound healing.

Choice D rationale

A temperature of 37.2 C (99 F) is within the normal range for body temperature. A slight elevation in temperature can be expected after surgery due to the body’s inflammatory response to the surgical trauma.

Condition: The client is most likely experiencing B. Acute Renal Failure. This is suggested by the client’s reported anuria (absence of urine), erythema around the arteriovenous fistula (AVF) site, and the CT scan showing distention with fluid and gas in the small intestine.

Action: The nurse should take the following actions to address this condition:

• A. Administer IV fluids as prescribed: This can help manage the client’s hydration and electrolyte balance.
• E. Administer pain medication as prescribed: This can help manage any discomfort the client may be experiencing.

Parameter: The nurse should monitor the following parameters to assess the client’s progress:

• A. Monitor blood pressure: Monitoring blood pressure is crucial in patients with acute renal failure as both hypotension and hypertension can occur.
• E. Monitor urine output: This is a key indicator of kidney function and should be closely monitored. Changes in urine output can provide early signs of improvement or deterioration in the client’s condition.